Child Find Referral Brevard -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 Brevard County.
Date of referral

MonthDayYear
Date
Referred by
Email
example@example.com
Referral source
Child's legal first name
Child's middle name
Child's legal last name
Child's date of birth
Child's gender
Child's birth city and state
Is the child Hispanic or Latino?
Child's race
What is the main concern for your child?
Who is the legal guardian?

Other
Does the child have a case manager?
Case manager name
Case manager phone number
(000)000-0000Format: (000) 000-0000.
Case manager email
example@example.com
Who does the child live with?

Other Relative
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
(000)000-0000Format: (000) 000-0000.
Primary contact email address
example@example.com
Secondary phone number
(000)000-0000Format: (000) 000-0000.
Child's primary language
Agencies serving the child
Does the child attend a preschool center?
Preschool center name
Days attending
Hours attending
Has the child had previous testing?
Where was testing completed?
File Upload for previous evaluations/reports

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Does the child have a medical diagnosis?
What is the medical diagnosis?
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?
Should be Empty:

FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM (FDLRS)

CHILD FIND REFERRAL

Child's Current Address