Child Find Screening Request For A Child With A Suspected Disability

Child Find Screening Request For A Child With A Suspected Disability

This form is only to be used if you suspect your child has a disability. Completion of this form will initiate a formal evaluation process for your child.

If you are looking to add your child the KIBSD PreK peer waitlist, please click here:

https://forms.office.com/r/xvDjmD9RMK

Today's Date *

Name of Person Completing this Screening Request*

Email of Person Completing Screening Request

Telephone Number of Person Completing Request*

Phone

Child's First Name*

Child's Middle Name or Initial*

(please enter N/A if not applicable)

Child's Last Name*

Child's Date of Birth*

Child's Gender*

Female

Male

Other

Child Lives With*

Current School Name and Grade (if applicable)

Physical Address*

Mailing Address*

Name of Parent/Guardian 1*

Email of Parent/Guardian 1

Contact Number 1 of Parent/Guardian 1*

Phone

Contact Number 2 of Parent/Guardian 1

Phone

Name of Parent/Guardian 2

Email of Parent/Guardian 2

Contact Number 1 of Parent/Guardian 2

Phone

Contact Number 2 of Parent/Guardian 2

Phone

Area(s) of Concern*

Speech = Making the sounds that become words.

Language = How words are used to make sentences when talking as well as how we listen and understand.

Adaptive = May need support with daily living skills like getting dressed, using the bathroom, or feeding themselves independently.

Behavioral/Social/Emotional = May need help regulating emotions, getting along with peers, or following home/classroom rules and expectations.

Fine Motor (OT) = Concerns with how the child's hands and fingers are working for tasks like coloring, using a utensil, and opening containers.

Gross Motor (PT) = Walking and running without falling frequently. Getting up and down off the floor or chair independently. Walking up and down the stairs without help. Balancing on one foot for a few seconds. Jumping up, down and over. Throwing and kicking a ball. Attempting to catch a ball.

Primary Language of the Child*

Primary Language Spoken at Home*

Is an Interpreter Needed*

Yes

Passed Most Recent Vision Screening*

Yes

N/A or Unknown

Passed Most Recent Hearing Screening*

Yes

N/A or Unknown

Child's Favorite Toy/Character/Show/Song

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