Parent/Guardian Child Find Referral Form
Child must reside in Charlotte County. This form is confidential only to Charlotte County Child Find Specialists.
If you are an agency, daycare or other provider, please see the separate agency referral form in the website link.
Name of Person Completing Form *
Your answer
Current Phone Number *
Please enter your phone number in the format ###-###-####.
Your answer
Email Address
Your answer
Is the child known to any other agencies? *
If yes which agencies?
Your answer
Child's First Name *
Your answer
Child's Middle Name
Your answer
Child's Last Name *
Your answer
Child's Age *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Child's Pediatrician
Your answer
Any other medical providers
Your answer
Mother or Legal Guardian's Name *
If legal guardian, documentation must be provided at screening.
Your answer
Father or Legal Guardian's Name *
If legal guardian, documentation must be provided at screening.
Your answer
Child Lives With *
Child's Current Street Address *
Your answer
City Child Lives In *
Your answer
State Child Lives In *
Please use 2 letter state abbreviation.
Your answer
Child's Zip Code *
Your answer
Primary Phone Number *
Please enter your number in the format ###-###-####.
Your answer
Secondary Phone Number *
Please enter your number in the format ###-###-####.
Your answer
Does the parent/guardian speak English? *
If not, what is the primary language?
Your answer
Does the child speak English? *
How did you learn about child find?
Your answer
Any medical diagnosis for the child? *
If answer is yes, you must provide documentation at the time of the screening.
If yes, what diagnosis?
Your answer
Please describe your area of concern for your child *
(i.e. delayed speech development, language development, behavior, overall developmental concerns, etc.)
Your answer
Is your child toilet trained? *
Does your child wear glasses? *
Has your child's hearing been tested? *
If yes, please provide documentation at screening.
Preschool(s) attending or attended: (if not attending a preschool, please say not attending) *
Your answer
Is your child currently attending a CCPS Early Childhood/(Headstart) program? *
Please provide any additional notes or comments:
Your answer
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