3-5 Child Find Referral

3-5 Child Find Referral

Child's Information:

Student's Full Name (first, middle, last)*

Date of Birth*

Student's Race

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Student's Ethnicity

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Gender

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Parent/Guardian Name:*

Relation to the child:*

Home Address:*

Parent phone:*

Parent email*

Child's Primary Language*

Language(s) Spoken in the Home

Interpreter needed?

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Preschool or child care experience:

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Other preschool or child care experience:

Areas of concern:*

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Please describe your concerns:

Supporting Documentation

Date of Hearing Screen:

Hearing Screen:

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Date of Vision Screen:

Vision screen:

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Please upload any supporting documentation

ASQ or developmental screenings
Assessment Data
Hearing and Vision Results
Hard copy of signed child find referral

Drag and drop files here or

Referral and Consent to Share Information

If you are not the parent/guardian please make sure that a parent/guardian has been notified of the referral submission.

Person or provider referring:*

Phone*

Email*

Parent/Guardian Consent for Screening

If not available consent for screening must be gained prior to screening.

I am requesting that my child be referred to Durango School District 9R Child Find for a developmental screening. I understand this process may lead to an evaluation for special education eligibility.

I give my consent for exchange of information between Durango School District 9R Child find and the referral source regarding the referral.

Parent/Guardian signature:

Date

Send me a copy of my responses

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