Request for Child Development Screening
Child's Name *
(First and Last name)
Gender *
Date of Birth *
MM/DD/YYYY
Parent's Names *
Address *
Phone Number *
Reason for Screening and Email Contact *
Please explain in detail the reasons why you would like to have your child screened. AND provide a reliable email that can be used for you and your child to participate in the screening process.
Did anyone other than parents suggest this screening? *
If so, who? If it was a teacher, please include the school that they work at
Has the child been evaluated by another agency, hospital, or clinic? *
If so, when and by whom?
Is this child receiving services by any agencies, hospitals, clinics or are they enrolled in a preschool setting? If yes, please provide the name of where they attend. *
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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