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FDLRS Springs Child Find Referral
FDLRS developmental screenings are intended for children ages 3 to 5 who have not yet entered kindergarten.
🔍Child Find Referral Information
Start by filling out your concerns and some basic information to help us begin the screening process.
What county does the child live in?
*
Alachua
Citrus
Dixie
Gilchrist
Levy
Marion
📅 Date of Referral
*
-
Month
-
Day
Year
Date
Who is referring the child?
First Name
Last Name
Referring Person's Relationship to the Child (e.g., parent, counselor, doctor).
📞 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What are your concerns about this child? (Check all that apply)
*
Learning
Speaking
Behaving
Seeing
Walking
Listening
Sensory
Other
Please tell us more about your concerns:
Back
Next
Child's Information
Please complete the following information about the child.
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Gender
*
Child's Race (Check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Decline to answer
Child's Ethnicity
Hispanic
Non-Hispanic
Decline to answer
Child's Primary Language
Family's Primary Language
Has the child been diagnosed with a medical condition by a doctor?
Yes
No
If yes, please list the medical diagnoses:
Has the child had any previous evaluations (medical, developmental, or school-based)?
Yes
No
If yes, please explain:
Family Information
Please have at least one parent/guardian complete this section. If you'd like to include a second parent/guardian, you may do so below.
Parent/Guardian 1 Name
*
First Name
Last Name
Parent/Guardian 1 Relationship to the Child
*
Parent/Guardian 1 Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Email
example@example.com
Parent/Guardian 2 Name
First Name
Last Name
Parent/Guardian 2 Relationship to the Child
Parent/Guardian 2 Best Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Email
example@example.com
Current Services
Tell us about any support your child is currently receiving.
Is the child currently receiving therapy or other services?
Yes
No
If yes, please describe the types of services the child is receiving: (e.g., speech therapy, occupational therapy, early intervention, private tutoring, etc.)
Is the child in daycare or preschool?
Yes
No
If yes, please enter the name of the daycare or preschool.
Is there anything else you’d like us to know about the child?
Submit
Should be Empty: