Lincolnshire-Prairie View Preschool Screening Form
Please complete this form so that we can determine the appropriate next steps for your child. Thank you! 
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Child Name *
Child Birthday *
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Child Age *
Address  *
Parent/Guardian Name #1
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Parent/Guardian Name #2
Parent/Guardian phone number #1
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Parent/Guardian phone number #2
Parent/Guardian email #1
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Parent/Guardian email #2
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Are there any languages other than English spoken in the home daily?
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Is your child currently receiving any services or have they received services previously?
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Does your child have any health needs or significant  health history affecting their development?
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Has your child received a vision and hearing screening?
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If yes, what was the date?
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DD
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Did they pass *
If they did not pass, briefly describe the results.
Does your child currently attend preschool or child care?
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If yes, where do they attend?
Has the preschool or child care shared any concerns regarding your child's development? If so, please explain.
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Do you have any concerns about your child's development in any of these areas: communication, fine motor, gross motor, social/emotional development, general concept development?
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Why are you seeking a screening for your child?
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Is there anything else you would like us to know about your child?
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I consent to District 103 and TrueNorth reaching out to the preschool or child care listed above, if necessary, to gather further information.
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