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*
MaleFemale
Child's birth city and state*
YesNo
WhiteBlack or African AmericanAsianAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander
What is the main concern for your child?*
Both parentsMotherFatherOther
YesNo
Case manager name*
Case manager phone number*
(000)000-0000Format: (000) 000-0000.
Case manager email *
example@example.com
Both parentsMotherFatherMother & Step FatherFather & Step MotherFoster ParentsOther 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
YesNo
Preschool center name*
Days attending*
Hours attending*
YesNo
Where was testing completed?*
File Upload for previous evaluations/reports

Cancelof
YesNo
What is the medical diagnosis?*
YesNo
What language is used in the home? *
YesNo
What is the child's first language?*
YesNo
What language is spoken most frequently?*
Should be Empty:

FLORIDA DIAGNOSTIC AND LEARNING RESOURCES SYSTEM (FDLRS)

CHILD FIND REFERRAL

Child's Current Address