Request for Child Development Screening
Child's Name *
(First and Last name)
Your answer
Gender *
Date of Birth *
MM/DD/YYYY
Your answer
Parent's Names *
Your answer
Address *
Your answer
Phone Number *
Your answer
Reason for Screening *
Please explain in detail the reasons why you would like to have your child screened.
Your answer
Did anyone other than parents suggest this screening? *
If so, who? If it was a teacher, please include the school that they work at
Your answer
Has the child been evaluated by another agency, hospital, or clinic? *
If so, when and by whom?
Your answer
Is this child receiving services by any agencies, hospitals, or clinics? *
Your answer
Does this child attend Head Start? *
Do you or this child require an interpreter for the screening? *
Date of Child Find Screening *
Time of Child Find Screening *
Please check ALL time slots that will work for you. We will do our best to work with your schedule and will call you to confirm the appointment time.
Required
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