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
February 4, 2019
March 4, 2019
April 1, 2019
April 29, 2019
September 9, 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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