Request for Child Development Screening
* Required
Child's Name
*
(First and Last name)
Your answer
Gender
*
Choose
Male
Female
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?
*
Choose
Yes
No
Do you or this child require an interpreter for the screening?
*
No
Yes
Date of Child Find Screening
*
Choose
October 1, 2018
October 29, 2018
December 3, 2018
January 2, 2019
February 4, 2019
March 4, 2019
April 1, 2019
April 29, 2019
June 3, 2019
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.
9:00 A.M.
10:00 A.M.
1:00 P.M.
2:00 P.M.
3:00 P.M.
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