CHILD FIND REFERRAL -VOLUSIA - FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM

FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM (FDLRS)
CHILD FIND REFERRAL
If the child you are referring is less than 2 years, 10 months of age please contact Early Steps to make a referral.

If you do not have concerns for your child’s development and are seeking childcare or VPK programming, please reach out to the Early Learning Coalition of Flagler & Volusia.
Date of Referral

MonthDayYear
Date
Referred By
Email
example@example.com
Referral Source
Child's Legal First Name
Child's Middle Name
Child's Date of Birth

MonthDayYear
Date
Child's Legal Last Name
Is the Child Hispanic or Latino?
Child's Gender
Child's Birth City and State
Child's Race
Who is the Legal Guardian?

Other
What is the main concern for your child?
Does the child have a case manager?
Case Manager Name
Case Manager Phone Number
Format: (000) 000-0000.
Case Manager Email
example@example.com
Who does the child live with?

Other
Legal Guardian/Parent/Caregiver First and Last Name
Relationship
Second Legal Guardian/Parent/Caregiver First and Last Name
Relationship
CHILD'S CURRENT ADDRESS
(Street)
(Apt/Lot #)
(City)
(Zip code)
Primary Contact Phone Number
Format: (000) 000-0000.
Primary Contact Email Address
example@example.com
Secondary Phone Number
Format: (000) 000-0000.
Child's Primary Language
Is a language other than English used in the home?
What language is used in the home?
Did the student have a first language other than English?
What is the child's first language?
Does the student most frequently speak a language other than English?
What language is spoken most frequently?
Did the child have previous testing completed?
Where was testing completed?
File Upload for previous evaluations/reports

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Are there any agencies serving the child? i.e. Easterseals, Speech Works, CMS, etc
Does the child attend Head Start?
Head Start Center Name
Does the child attend Preschool/Daycare?
Name of Preschool/Daycare
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FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM (FDLRS)

CHILD FIND REFERRAL

CHILD'S CURRENT ADDRESS