CVSD Early Education Intake Form (3 to 6 Year Old)
Use this form to make a referral to CVSD Early Education for concerns about a preschool-aged child's development in one or more areas.  Once this referral is received, a member of our early education team will reach out to you with the Ages and Stages Questionnaires and will follow up on next steps. 
Email *
Today's Date
MM
/
DD
/
YYYY
Name of person making referral
Phone number of person making referral
Child's Name
Child's Date of Birth
MM
/
DD
/
YYYY
Child's Age
Parent/Guardian(s)
Address
Parent Phone
Parent Email Address
Reason for Referral
Please describe the reason for this referral
Is the parent/guardian aware of this referral?
Clear selection
What other services are the child and/or family receiving?
What is the primary language spoken in the home?
Other languages spoken in the home?
Has the child had a previous screening or evaluation? If so, please explain.
Has the child had a hearing test?
Clear selection
Has the child been to the Luse Center for Communication Disorders?
Clear selection
Does the child attend preschool or childcare? Please list program name, location, teacher's name, and hours.
Does CVSD have verbal permission from the parent/guardian to speak with the child's early educators or childcare providers?
Clear selection
What do you hope will happen as a result of this referral?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Champlain Valley School District.

Does this form look suspicious? Report

Google Forms