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*
YesNo
MaleFemale
Child's Birth City and State*
WhiteBlack or African AmericanAsianAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander
Both ParentsMotherFatherOther
What is the main concern for your child?*
YesNo
Case Manager Name*
Case Manager Phone Number *
Format: (000) 000-0000.
Case Manager Email*
example@example.com
Both parentsMotherFatherMother & Step FatherFather & Step MotherFoster ParentsOther
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*
YesNo
What language is used in the home?*
YesNo
What is the child's first language?*
YesNo
What language is spoken most frequently?*
YesNo
Where was testing completed?*
File Upload for previous evaluations/reports

Cancelof
Are there any agencies serving the child? i.e. Easterseals, Speech Works, CMS, etc
YesNo
Head Start Center Name*
YesNo
Name of Preschool/Daycare*
Should be Empty:

FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM (FDLRS)

CHILD FIND REFERRAL

CHILD'S CURRENT ADDRESS