Child Find Screening Form 
Regular screening and assessment activities are conducted to identify preschool aged children (approx. 3-5 years) that may have a disability and be in need of special education services. Screenings are generally held once per month.
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Email *
Parent/Guardian's name(s) *
Full home address  *
Phone number(s) *
Child's full name  *
Child's date of birth  *
MM
/
DD
/
YYYY
What is the major concern regarding this child? *
Required
Are there any medical conditions/diagnosis? 
(Note: school districts do not diagnose)
 *
If yes or in process, please describe: 
Any current reports/assessments (medical and/or educational) completed within the past year?  *
If yes, name of agency/doctor: 
Please provide copies if available upon appointment. 
Has child attended any preschool and/or daycare? *
If yes, name and person of contact/information
Any other alternatives (i.e.. mommy and me classes, sports, dance, church groups, play groups, community events, play dates)
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