FDLRS Emerald Coast Child Find Screening Form

FDLRS Emerald Coast Request for Screening
Directions: Please complete the form below. In the Parent section, please provide the name, phone number, and email address of the child’s parent/guardian. Once submitted, you will receive a copy of your completed form. A Child Find Specialist will contact the child’s parent/guardian to schedule a screening appointment. A referral from a physician is not necessary. No insurance is required.
Do you suspect your child has a developmental, speech, or language delay?

Find information on early learning services:

Early Learning Coalitions:
- Escambia County: elcescambia.org 📞 850-595-5400
- Emerald Coast (Okaloosa/Walton): elc-ec.org/ 📞 850-833-3627
- Santa Rosa County: elcsantarosa.org 📞 850-983-5313
Head Start / Early Head Start: Visit flheadstart.org/how-to-apply

Eligible children: Birth–age 5 (income-qualified, foster care, homeless, or receiving SNAP/TANF/SSI).

Since your child is currently enrolled in a Head Start program, you will need to share your concerns with your child's teacher or school counselor to begin the screening process.

Is your child aged 2 years 9 months through 5 years old AND NOT enrolled in public school?

PARENT AND ADDITIONAL INFORMATION
E-mail Address of Person Completing Form
example@example.com
Are you the parent?
redirectURL
Which county do you live in?
FDLRS Emerald Coast serves only Escambia, Okaloosa, and Santa Rosa counties. If you live in a different county, please find your local FDLRS center at www.fdlrs.org
Parent/Guardian's Name

First NameLast Name
Relationship to child
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your residence address the same as your mailing address?
Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Other Contact Information
alternate phone number (if needed)Format: (000) 000-0000.
School Zone
If you know the School/Bus Zone your child resides in, please include it here. If you do not know, please leave this blank.
Area of Concern
Medical Concerns
Prior Therapy/Evaluations
File Upload (optional)

Most recent private evaluations and reports, if available.
Cancelof
Should be Empty:

FDLRS Emerald Coast Request for Screening