JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
CHILD FIND INTAKE
Utilized to gather information from parents requesting evaluations.
Sign in to Google
to save your progress.
Learn more
* Required
Email
*
Your email
Child's Name
*
Your answer
Gender
Female
Male
Clear selection
Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth
*
Your answer
Home Address
*
Your answer
Parent/Guardian's Name
*
Your answer
Phone #
*
Your answer
Parent/Guardian's Name
Your answer
Phone #
Your answer
Who does the child primarily live with?
*
Mother
Father
Both parents
Stepmother
Stepfather
Grandparents
Other:
Required
Siblings & Ages
Your answer
Language(s) spoken in the home
*
English
Spanish
Other:
Required
Language(s) child understands
*
English
Spanish
Other:
Required
Language(s) child speaks
*
English
Spanish
Other:
Required
Does the parent or child need an Interpreter?
*
Yes
No
Does the child participate in a childcare program, Mother's Day Out program or preschool program?
Yes
No
Other:
Clear selection
Does the child currently receive any type of therapy or services (speech therapy, OT, PT, etc.)?
Your answer
Is your child currently under the care of a physician?
*
Yes
No
Other:
Are there any concerns with your child's vision?
*
Yes
No
Other:
Are there any concerns with your child's hearing?
*
Yes
No
Other:
What concerns do you currently have about your child?
*
Your answer
Speech/Language
*
My child only has a few words in vocabulary; doesn't put words together to communicate.
My child doesn't seem to understand; has difficulty following directions.
My child is hard to understand; speech is unclear.
My child stutters or unable to speak with fluency.
No concerns
Other:
Required
Social
*
Consistently shows limited/no interest in interacting or socializing with others
Rarely makes eye contact (looks at) others
Does not share well with others or take turns, even with guidance
Often prefers playing alone rather than playing with other children
Focuses on a single topic or toy at a time, sometimes obsessively and becomes upset if not allow to persist with the topic or toy
No concerns
Other:
Required
Social - If one or more items were marked above, please describe what the behavior looks like, how often does it occur and how severe is it.
Your answer
Emotional/Behavioral
*
Refuses to comply with requests
Self-injures (punching, scratching themselves)
Performs repetitive motions (flaps hands, rocks back and forth, spins)
Has persistent, severe temper tantrums where he/she is not easily soothed or calmed
Excessively aggressive with others
Has odd routines and gets upset when not allowed to carry them out (such as always wanting to close doors)
No concerns
Other:
Required
Emotional/Behavioral - If one or more items were marked above, please describe what the behavior looks like, how often does it occur and how severe is it.
Your answer
Attention
*
Restless; constant need for movement
Gets upset, frustrated by small changes in daily routine
Short attention span (unable to pay attention to a single task for 3 or more minutes)
No concerns
Other:
Required
Developmental/Cognitive
*
Delays in meeting developmental milestones
Difficulties learning new skills (behind peers)
Difficulties repeating information just heard (for example - if you say, 1, 2, 3 can they repeat it back.)
Difficulties imitating or copying a pattern up to four objects (for example - a line of cars, blocks or familiar objects)
No concerns
Other:
Required
Self-Help
*
Significant delay in feeding
Significant delay in dressing
Significant delay in toilet training
No concerns
Other:
Required
Any additional information you would like to share about your child.
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Forney ISD.
Report Abuse
Forms
