Early Explorers: Initial Intake Questionnaire

Thank you for your interest in Early Explorers! We'd love to learn a bit more about you so that we can best meet your needs. Please take a few minutes to complete the form below, and a member of our team will be in touch. Thank you!

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Name of Respondent *
Email Address *
Phone Number *
Respondent's Relationship to Child *
Name of Child *
Is your child between the ages of 0 and 36 months?
 *
Child's Date of Birth (DoB) *
City of Residence and/or Zip Code 
Early Explorers currently provides services within Riverside, San Bernardino, Imperial, and San Diego counties.
 *
Do you have concerns about your child's development? If so, please explain.
Has your child been evaluated for a developmental delay?  *
How involved are you looking to be in services for your child?
 *
I do not want and/or am unable to participate heavily in my child's services.
I want to be very involved and take the lead in my child's services
Do you grant permission for a member of our team to contact you via phone call and/or text message to provide more information?  *
Is there anything else you would like us to know?
How did you hear about Early Explorers? *
Required
If you were referred by a provider and/or Regional Center, please indicate their name.
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