Child Find Palm Beach County Referral

Palm Beach County Child Find Referral
FDLRS Alpha developmental screenings are intended for children ages 3 to 5 with developmental delays who reside in Palm Beach County, have not entered Kindergarten, and are not enrolled in a school district program. If you need help with completing this form, please call our Child Find intake phone number at 561-434-7337.
If you DO NOT have concerns about your child's development and are seeking childcare or VPK programming, please reach out to the Early Learning Coalition of Palm Beach County.
Child Find Referral Information

You can start by filling out your concerns and some basic information to help us begin the screening process. All fields marked with * are required and must be filled out.
Date of Referral

MonthDayYear
Date
Name of person completing this form:*

First NameLast Name
Referring person's relationship to the child (parent, doctor, family member, etc.)
YESNO
Name of agency:*
Name of agency staff member:*

First NameLast Name
Agency Staff Phone Number:*
Please enter a valid phone number.Format: 000-000-0000.
Extension
Email of agency staff member:*
Additional email of agency staff:
YESNO
Please note, the parent will receive an automated email with next steps in the process. Upload all supporting documents (screenings/evaluations) to the dropbox at the end of this referral.
Phone Number of person completing this form*
Please enter a valid phone number.Format: 000-000-0000.
SpeakingLearningBehavingListeningWalkingSensory (vision/hearing)Other (explain below)
Please tell us more about your concerns:*
Please be specific and give examples.
Child's Information

Please complete the following information about the child.
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth (ages 3 - Kindergarten entry only)*

MonthDayYear
femalemale
American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhiteDecline to answer
HispanicNon-HispanicDecline to answer
Child's Primary Language*
List all that apply
Family's Primary Language*
List all that apply
Fluent, no interpreter neededMarginal, some EnglishNone, need interpreter
Preferred language for emails and formal documents:*
Please note that English will be used if other than Spanish, Creole or Portuguese.
YesNo
If yes, please explain and upload to the dropbox at the end of this referral:
Family Information

Information for at least one parent/guardian is needed for this section.
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Phone Number*
Please enter a valid phone number.Format: 000-000-0000.
Secondary Phone Number
Format: 000-000-0000.
Email Parent/Guardian 1 *
Forms and next steps will be sent to this email address. Please call our intake line to make the referral if you do not have an email (561)434-7337.
Relationship to Child*
Parent/Guardian 1 Primary Address*

Street Address

Mailing Address (if different from above) P.O. Box, etc.

CityState

Zip Code
City
State
Zip Code
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Relationship to the Child
Email Parent/Guardian 2
Current Services

Tell us about any support your child is currently receiving.
YesNo
If yes, please describe the types of services the child is receiving: (speech therapy, occupational therapy, early intervention, agency services, ABA, etc.)
YesNo
If yes, enter the name of the daycare or preschool.
Is there anything else you would like us to know about the child?
FILE UPLOAD Please upload any previous reports, evaluations or records.

Cancelof
DBN
Kindergarten Entry Year
SAC School
Status
Notes
You will receive an automated email response with next steps. Please check your spam/junk folder.
Should be Empty:

Palm Beach County Child Find Referral

Child Find Referral Information

Child's Information

Family Information

Current Services

You will receive an automated email response with next steps. Please check your spam/junk folder.