Child Find Referral Packet

Today's Date

MonthDayYear

Were you referred to Child Find by an Agency?

How did you hear about Child Find?

Referred By:

Individual’s Name/Relationship to Child

Referral Source Phone:

(000) 000-0000Format: (000) 000-0000.

Referral Source E-mail:

example@example.com

Referring Source:

Agency Name/Department

Source is a Child Protection Agency?

Child’s Full Name:

Date of Birth

MonthDayYear

Child's Age

Child's Sex:

Child's City of Birth:

Child's Race:

Hispanic:

Language(s) Spoken at Home:

If other than English, please specify

Receiving protective services:

Agency/ChildNet Advocate:

Attending preschool:

Specify location/program:

The child lives with:

Person's Name:

Person's E-mail:

example@example.com

Person's Address:

Home Address

Apt #

City

ZIP

Person's Phone Numbers:

Rows	(000) 000-0000
Cell
Home
Work

Alternative Contact:

Relationship to Child:

Phone:

(000) 000-0000Format: (000) 000-0000.

Reason for Referral

Medical Diagnosis:

Specify Medical Diagnosis:

Developmental Services the child is currently receiving:

Location of Services:

Comments

Home School

CHILD'S NAME:

CHILD'S DATE OF BIRTH:

MM/DD/YYYY

Child's Age

CHILD' S SEX:

LANGUAGE(S) SPOKEN IN HOME:

LANGUAGE SPOKEN TO CHILD:

Address:

Home Address

Apt #

City

ZIP

Please provide mother's information

Rows
Name
Cell #
Home #
Email

Please provide father's information

Rows
Name
Cell #
Home #
Email

Marital Status of Parents: (Check One)

How old was the child when the separation/divorce occurred?

Did you adopt this child?

What was the date of the adoption?

MM/DD/YYYY

Is Child Protective Services Involved?

CPS Involvement but child remains with Natural Parent(s)

Home Address

Street, Apt. City Zip

Out of Home Placement:

Placed with:

Identify Contact:

Caregiver’s Name

Care Giver's Home #

Caregiver's Cell #

Caregiver's Address

Street, Apt. City Zip

Agency Caseworker’s Name

Phone #

(000) 000-0000Format: (000) 000-0000.

Agency Name

LIST EVERYONE WHO LIVES IN THE HOUSEHOLD

Rows	Name	Age	Sex	Relationship to the Child
1
2
3
4

Upload additional page if necessary

Please list additional household members information

City of Birth

State/Country of Birth

Complications during pregnancy (if any)

Weeks/Months Carried

Birth was (Check One)

Birth Weight

Complications during birth (If any)

What was Mother’s condition after delivery?

What was Baby’s condition after delivery?

Has the child ever been diagnosed with a medical condition?

Name of condition

Date of last physical exam

MM/DD/YYYY

Results

Check and note the age of the child if they have had any of the illnesses/conditions listed:

Rows	Yes	Age	No
Cyanosis (turning blue)
Jaundice (yellow)
Convulsions/Seizures
Hemorrhage
Skin Eruption
Asthma
Bronchitis
Scarlet Fever
Chicken Pox
Polio
Encephalitis
Frequent Colds
Kidney Disease
Malformations
Feeding difficulty
Sleeping difficulties
Headaches
Excessive crying
Diabetes
Visual problems

Check and note the age of the child if they have had any of the illnesses/conditions listed:

Rows	Yes	Age	No
Colic
Mumps
Meningitis
Diptheria
High Fever ((over 104°)
Ear injuries
Frequent Ear Infection
Draining Ears
Tubes in ears
Tonsillitis
Adenoidectmy
Measles
Sinisitis
Tonsillectomy
Head injuries
Swallowing/sucking difficulties
Rheumatic fever
Pneumonia
Excessive Tearing
Cleft lip/Palate

Indicate any the child has had.

Rows	Check	Please Describe	AGE
Serious Accident or injuries
Surgeries
Allergies
Other
None

NAME of PRIMARY CARE PHYSICIAN/PEDIATRICIAN

Rows	Name	Address	Phone Number
Primary CarePhysician

Specialist Physicians

Rows	NAME and TYPE of SPECIALIST(S)	ADDRESS	PHONE NUMBER

List any assistive/adaptive devices the child uses (ex: prosthetics, mobility devices, communication aids)

Type N/A if not applicable

List any medical devices the child uses (ex: respirator, g-tube, oxygen)

Type N/A if not applicable

LIST ANY MEDICATIONS THE CHILD IS TAKING AT THIS TIME AND THE REASON WHY

Rows	Name of Medication	Dosage	Time(s) taken	Date prescribed	Reason

PLEASE INDICATE THE AGE AT WHICH THE CHILD FIRST DEMONSTRATED EACH OF THE FOLLOWING DEVELOPMENTAL BEHAVIORS (Mark N/A if Unknown)

Rows	Age	N/A
Showed response to mother:
Followed objects with eyes:
Turned toward noise:
Smiled:
Held head up:
Babbled:
Spoke first words:

PLEASE INDICATE THE AGE AT WHICH THE CHILD FIRST DEMONSTRATED EACH OF THE FOLLOWING DEVELOPMENTAL BEHAVIORS (Mark N/A if Unknown)

Rows	Age	N/A
Rolled Over:
Crawled:
Stood alone:
Sat alone:
Walked alone:
Toilet trained:

Child’s development appeared normal up to age:

Check the statement that best describes the child’s language development:

Check any behavior problems the child currently exhibits:

Is there any family history of developmental delay?

Please explain the Developmental Delay.

Do you feel the child is having difficulty at home?

Please explain the difficulty the child is having at home.

Do you feel the child is having difficulty at school?

Please explain the difficulty the child having at school.

Other Concerns:

Please explain in detail

Your observations/knowledge of the child’s strengths/weaknesses will prove a useful part of the evaluation process.

The child’s favorite activity/toy:

The child’s least favorite activity/toy:

I would describe the child as:

The child is good at:

Changes/progress I have noticed in the child recently:

Some of my hopes for the child are:

Information/services that I need to help my child:

Does or has the child attended preschool?

List preschools the child has attended:

Rows	Name	Location	Date Started	Reason for leaving
1
2
3

Who cares for him/her during the day?

Has the child ever had any of the following evaluations?

Rows	Yes	Date	Completed By:	Phone #	Address
Psychological/Developmental
Psychiatric
Speech/Language
Hearing
Vision
Occupational Therapy
Physical Therapy
Neurological
None

Please upload copies of any evaluations marked Yes above.

Please upload evaluations

Is there a pending referral?

Date of pending referral:

For what type of evaluation?

Is the child currently receiving therapy?

Please provide information for any therapies the child receives

Rows	Yes	Timed per Week	Agency	Phone #	Address
PT-Physical Therapy
OT-Occupational Therapy
ST-Speech Therapy
ABA-Behavior Therapy

Are there other agencies/clinics/social services assisting child/family?

Other agencies/clinics/social services assistingchild/family

Rows	Name of Agency/Clinic/Social Service	Contact Person	Services Provided
1
2
3
4

Diet Type:

Food Preferences:

Food Dislikes

Eating:

Dressing:

Needs help with:

Toileting:

Needs help with:

Sleeping Habits:

Rest Times:

Name of Child

Child's Date of Birth

00/00/0000

Date

Completed by:

First NameLast Name

Social and Emotional

Rows	Yes	Comments	No
Affectionate, loving
Appears to enjoy school
Plays appropriately with toys
Plays appropriately with other children
Has a few friends
Has no friends
Avoids or is uncomfortable with other children
Unwilling to share toys
Does not want to participate in activities
Seeks attention (“Watch me!”)
Usually is happy
Shows little emotion
Difficulty separating from parent
Withdraws, likes to be left alone
Shows remorse; is sorry

Does the child show too much emotion?

Which does the child display too much of? (Check all that apply)

Does the child hurt others?

Does the child hurt others...

Sensory and Motor

Rows	Yes	Comments	No
Often bumps into things
Falls frequently

Does the child demonstrate unusual behaviors? (such as flapping, banging head)

What unusual behaviors does the child demonstrate? Check all that apply.

Other

Does the child often not respond to sounds?

The child has been diagnosed with hearing loss.

Child is overly sensitive to sounds/smells/touch/textures

What is the child overly sensitive to?

Self Help

Rows	Yes	Comments	No
Feeds self
Washes hands
Helps with simple chores
Avoids common dangers (hot stove, broken glass)
Uses toilet independently
Dresses Self Independently
Dresses Self with Help
Wears diapers or pullups
****And tells an adult when needs changing
Uses toilet with help
****And tells an adult when needs to go

Communication

Rows	Yes	Comments	No
Makes and maintains eye contact
Uses gestures (points, waves goodbye)
Uses facial expressions (smiles, frowns)
Understands your gestures (looks where you point)
Vocalizes, uses sounds
Repeats words to learn them
Uses words to communicate
Uses sentences to communicate
Follows simple directions
Repeats words and phrases for no clear reason
Echoes what he hears
Repeats commercials, videos, etc
Uses jargon or gibberish
Uses words but does not speak clearly
Has difficulty answering simple questions

Compliance

Rows	Yes	Comments	No
Seeks to please
Usually is cooperative
Difficulty changing from one activity to another
Difficulty handling a change in the usual routine
Insists on having his/her way
Resists behavioral limits

Does the child have difficulty following directions?

Does the child have difficulty following directions because... (check all that apply)

Self-Control

Rows	Yes	Comments	No
Shows good self-control
Does not stick with an activity or finish tasks
Often has tantrums
Loses control; has a “meltdown”
Requires supervision most of the time
Aggressive words (calls people names, bad language)

Does the child have poor focus and control?

Is the poor focus and control because the child is.. (check all that apply)

Does the child display aggressive actions. (hits, kicks, throws)

Are the aggressive behaviors towards...(check all that apply)

THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA

Exceptional Student Education

FDLRS / Child Find Referral Form Children Ages 3 to 5 Years

Child's Housing

754-321-7200 -Child Find Referral Line

PRE-K INFORMATION SURVEY

PREGNANCY, BIRTH AND DEVELOPMENTAL HISTORY

MEDICAL HISTORY

Educational History

SELF-CARE:

EARLY CHILDHOOD PARENT QUESTIONNAIRE