FDLRS Island Coast Child Find Referral

Child Find Referral

FDLRS Island Coast Associate Center Serving Collier and Lee Counties
If the child you are referring is under 2 years, 10 months old, please contact: https://hpcswf.com/programs/early-steps/early-steps-program

If the child you are referring is over 6 years old, please contact Renae Seguin, Parent and Family Services Specialist, at renaekl@leeschools.net or 239-337-8539.

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Step 1: Fill out the referral below.

Step 2: Once a PARENT completes the referral, a new green form will appear that you must complete and submit. (If you are not the parent, you only need to submit the referral).
Name of Child

First NameLast Name
Child's Date of Birth
MM/DD/YYY
Is the child younger than 2 years and 10 months old?
Is the Parent/Guardian submitting this referral?
Name of Person Completing This Form

First NameLast Name
Email of Person Making Referral
example@example.com
Relationship to Child
Phone Number of Person Making Referral
Please enter a valid phone number.Format: (000) 000-0000.
What county do you live in?
Does your child have an IEP (Individualized Education Plan)?
Does your child currently attend public school?
Which Collier County School does your child attend?
Which Lee County School does your child attend?
Child's Gender
Child's Race
Child's Ethnicity
Languages Spoken in the Home
Mother or Legal Guardian Name

First NameLast Name
Father or Legal Guardian Name

First NameLast Name
Who does the child live with?

Other
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Reason for Referral (Areas of Concern)

0/100
Currently attending daycare or preschool?
If Yes, name of current daycare, preschool or school
Important Medical History or Diagnosis?
Is your child receiving any private therapy services? If so, where and how often?
Should be Empty: