Child Find Referral Packet

THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA
Exceptional Student Education
FDLRS / Child Find Referral Form Children Ages 3 to 5 Years
Today's Date

MonthDayYear
Were you referred to Child Find by an Agency?*

YesNo
Which agency referred you?*

211 BrowardChildNetChildren’s Diagnostic and Treatment Center (CDTC)Early Learning Coalition of Broward (ELC)Early StepsESE Private SchoolsHelp me GrowJewish Adoption and Family Care Options(JAFCO)Joe DiMaggio Children’s Hospital (JDCH)Memorial Mobile VanPediatric AssociatesSeminole Tribe of FloridaUnknownOther
Referred By:*
Individual’s Name/Relationship to Child
Referral Source Phone:*
(000) 000-0000
Referral Source E-mail:*
example@example.com
Referring Source:*
Agency Name/Department
Source is a Child Protection Agency?*

YesNo
Child’s Full Name:*
Date of Birth

MonthDayYear
Child's Age
Child's Sex:*

MaleFemale
Child's City of Birth:*
Child's Race:*
Hispanic:*

YesNo
Language(s) Spoken at Home:*
If other than English, please specify*

MinimalBothPrimary
Receiving protective services:*

YesNo
Agency/ChildNet Advocate:*
Attending preschool:*

YesNo
Specify location/program:*
Child's Housing
The child lives with:*

ParentFoster ParentRelativeGuardian
Person's Name:*
Person's E-mail:*
example@example.com
Person's Address:*

Home Address

Apt #

CityState / Province

ZIP

Person's Phone Numbers:*

	(000) 000-0000
Cell
Home
Work

Alternative Contact:
Relationship to Child:
Phone:
(000) 000-0000
Reason for Referral*

Speech (hard to understand, talking is not clear)Expressive Language (few words in vocabulary)Receptive Language (doesn’t seem to understand, difficulty following directions)Social-Emotional (interaction with others, social skills)Cognition (seems behind, difficulty retaining information)Behavior (aggressive, harms self or others, inattentive, active)Fine Motor holding, drawing, grasping, picking up smallGross Motor (clumsy, falls a lot, poor coordination or balance)Self-Help (independent functioning, toileting, feeding, dressing)Vision DiagnosisHearing Diagnosis
Medical Diagnosis:*

YN
Specify Medical Diagnosis:*
Developmental Services:*

Speech/LanguageOTPTBehaviorNone
Location of Services:*
Comments
Home School*
754-321-7200 -Child Find Referral Line
PRE-K INFORMATION SURVEY
CHILD'S NAME:*
CHILD'S DATE OF BIRTH:*
MM/DD/YYYY
Child's Age
CHILD' S SEX:*

MaleFemale
LANGUAGE(S) SPOKEN IN HOME:*
LANGUAGE SPOKEN TO CHILD:*
Address:*

Home Address

Apt #

CityState / Province

ZIP

Please provide mother's information*


Name
Cell #
Home #
Email

Please provide father's information


Name
Cell #
Home #
Email

Marital Status of Parents: (Check One)*

SingleMarriedSeparatedDivorcedWidowed
How old was the child when the separation/divorce occurred?*
Did you adopt this child?*

YN
What was the date of the adoption?*
MM/DD/YYYY
Is Child Protective Services Involved?*
CPS Involvement but child remains with Natural Parent(s)*

YesNo
Home Address*
Street, Apt. City Zip
Out of Home Placement:*

Yes
Placed with:*

RelativesShelter CareFoster CareSkilled Nursing FacilityOther
Identify Contact:*

ParentsFoster Parent(s)Relative Guardian/CaregiverAgency Case Worker
Caregiver’s Name*
Care Giver's Home #
Caregiver's Cell #*
Caregiver's Address*
Street, Apt. City Zip
Agency Caseworker’s Name*
Phone #*
(000) 000-0000
Agency Name*

LIST EVERYONE WHO LIVES IN THE HOUSEHOLD*

	Name	Age	Sex	Relationship to the Child
1
2
3
4

Upload additional page if necessary

Please list additional household members information
Cancelof
PREGNANCY, BIRTH AND DEVELOPMENTAL HISTORY
City of Birth*
State/Country of Birth*
Complications during pregnancy (if any)
Weeks/Months Carried
Birth was (Check One)

NormalCaesareanBreech
Birth Weight
Complications during birth (If any)
What was Mother’s condition after delivery?
What was Baby’s condition after delivery?
MEDICAL HISTORY
Has the child ever been diagnosed with a medical condition?*

YesNo
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:*

	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:*

	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.*

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

NAME of PRIMARY CARE PHYSICIAN/PEDIATRICIAN*

	Name	Address	Phone Number
Primary CarePhysician

Specialist Physicians

	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

	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)*

	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)*

	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:*

Follows simple directions.Understands everything said to him/her.Speaks in phrases or short sentences.Engages in appropriate conversations.Does not do any of the above
Check any behavior problems the child currently exhibits:*

Does not get along with other children.Does not get along with adults.Prefers to be alone.Is too active.Is physically aggressive.Is stubborn.Wets the bed.Has difficulty with speech/language.Does your child have a hearing aid?Has difficulty with vision.Does your child wear glasses?Does not display any of the above behaviorsOther: (Explain/Describe)
Is there any family history of developmental delay?*

YesNo
Please explain the Developmental Delay.*
Do you feel the child is having difficulty at home?*

YesNo
Please explain the difficulty the child is having at home.*
Do you feel the child is having difficulty at school?*

YesNo
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:*
Educational History
Does or has the child attended preschool?*

YesNo

Who cares for him/her during the day?*

Has the child ever had any of the following evaluations?*

	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
Cancelof
Is there a pending referral?*

YN
Date of pending referral:*
For what type of evaluation?*
Is the child currently receiving therapy?*

YesNo

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

YesNo

Diet Type:*

RegularPureedGroundChopped
Food Preferences:*
Food Dislikes*
SELF-CARE:
Eating:*

DependentHand-over-handFinger-feedindependentUses Adaptive Equipment (Please List)
Dressing:*

DependentNeeds Some AssistanceIndependent
Needs help with:*
Toileting:*

DiapersTraining PantsIndependent
Needs help with:*
Sleeping Habits:*
Rest Times:*
EARLY CHILDHOOD PARENT QUESTIONNAIRE
Name of Child*
Child's Age*
Date*
Completed by:*

First NameLast Name

Social and Emotional*

	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?*

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

UpsetFearfulAngryCries
Does the child hurt others?*

YesNo
Does the child hurt others...*

on purposewithout meaning to

Sensory and Motor*

	Yes	Comments	No
Often bumps into things
Falls frequently

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

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

Rocks back & forthFlaps HandsBangs headOther
Does the child often not respond to sounds?*

YesNo
The child has been diagnosed with hearing loss.*

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

YesNo
What is the child overly sensitive to?*

SoundsSmellsTouchTexture

Self Help*

	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*

	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*

	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?*

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

Doesn't understandDoesn't want to

Self-Control*

	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?*

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

distractedimpulsivecan't be still
Does the child display aggressive actions. (hits, kicks, throws)*

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

objectschildrenadultsself
FDLRS is funded by the Florida Department of Education, Division of Public Schools, Bureau of Exceptional Education and Student Services, through federal assistance under the Individuals with Disabilities Education Act Part B and State General Revenue funds. Section 1006.03, Florida Statutes (F.S.) - Diagnostic and Learning Resource Centers
Should be Empty:

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

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

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