Child Find Request for Assistance
This form is for preschool and 4K age children who reside in the Stoughton Area School District attendance area. By filling out the form below you are requesting a screening for your child. If you would like to request a referral for a Special Education evaluation, please complete the form and call the Child Find number at (608) 877-5403.
Email address *
Child's Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Select one or more of the following categories that apply to this child *
Primary Language *
Your answer
Other Languages Spoken in the Home
Your answer
On weekdays the child is at *
If you checked "Other" above, please describe
Your answer
Please indicate the child's schedule Monday-Friday and location *
Your answer
School Attendance Area *
Parent/Guardian Name
Your answer
Street Address
Your answer
City
Your answer
Zip Code
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Name of the person making the request *
Your answer
Relationship to the Child *
Your answer
How long have you known this child *
Your answer
Name and address of the preschool/childcare center
Your answer
Contact person at the preschool/childcare center
Your answer
Phone of the preschool/childcare center
Your answer
Please provide a short description of the child's likes, interests, strengths *
Your answer
This request is for concerns in the area(s) of (check all that apply) *
Required
If you marked "Other" please describe
Your answer
For each item checked, please provide a detailed description of the concern *
Your answer
Give specific examples of what the concern looks like in the home, preschool and/or community *
Your answer
Describe what you have tried to address the concerns above. Include a description of strategies and the length of time these interventions were in place *
Your answer
Has the child had an evaluation in any area of development (check all that apply)
If you checked "Other" please provide more information
Your answer
For each checked above, please email reports to Mindy Holverson, mindy.holverson@stoughton.k12.wi.us
Does you child have a medical diagnosis (i.e., speech and language impairment, Autism, ADHD, etc.)? *
If your child has a medical diagnosis, please provide more information
Your answer
Does the child receive services from an outside agency (i.e., rehab clinic, speech therapy, Autism therapy, etc.)
If the child receives services from an outside agency, please provide more information
Your answer
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