FDLRS Child Find Intake Form
Please complete this form if you have concerns about your child's development, speech, or behavior
Date
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/
Month
/
Day
Year
Date
Does your child have an IEP/PEI from any other country or state?
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Yes
No
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Does your child receive services through Early Learning Coalition (i.e. Voucher)?
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Yes
No
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Does your child receive services through Early Steps?
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Yes
No
Does your child have an IFSP from any other county or state?
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Yes
No
Are there any other agencies involved with your child?
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Yes
No
If yes, please specify:
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Child's Information
Child's Legal First Name:
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Middle Name:
Child's Legal Last Name:
*
Child's Age:
*
Child's Date of Birth:
*
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Month
-
Day
Year
Date
Child's Sex:
*
Male
Female
Child's Race:
*
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White/Caucasian
I do not wish to provide this information
Child's Ethnicity (Hispanic):
*
Yes
No
What language does your child speak and understand most fluently?
*
Do you need an interpreter?
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Yes
No
Upload Child's Birth Certificate
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Parent/Guardian's Information
Mother's Name:
Phone:
Format: (000) 000-0000.
Email:
Confirmation Email
example@example.com
Father's Name:
Phone:
Format: (000) 000-0000.
Email:
Confirmation Email
example@example.com
Does the child live with his/her parent(s)?
*
Yes
No
Child lives with:
If not parent, name of primary caregiver:
Relationship:
Phone:
Format: (000) 000-0000.
Email:
Confirmation Email
example@example.com
Residential Address:
*
Mailing Address
Street Address Line 2
City
State
Zip
Mailing address same as residential?
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Yes
No
Mailing Address:
Mailing Address
Street Address Line 2
City
State
Zip
Primary Concerns:
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Current School or Program
Does your child attend any of the following? (Check all that apply)
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Daycare/Preschool
School Rediness
Head Start
VPK
None
If yes, program name:
Zoned School
Not sure of your child's zoned school? Use the Zone Finder link. https://azua.polk-fl.net/
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Development & Health
Was your child born early?
*
Yes
No
If yes, how early?
Has your child been screened or tested by any other professionals/specialist?
*
Yes
No
If yes, describe:
Upload any relevant screening/testing results
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Do you have any of the following concerns about your child? (Check all that apply)
Health
Hearing
Behavior
Physical Limitations
Visual Tracking
Speech/Language
None
Describe concerns:
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Referral Information
Person/Program that referred the child:
Person completing form:
*
Relationship to child:
Phone:
Format: (000) 000-0000.
Email:
*
Confirmation Email
example@example.com
How did you hear about us?
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FDLRS FUNCTIONAL VISION AND HEARING SCREENING QUESTIONNAIRE
Date
*
/
Month
/
Day
Year
Date
Form completed by:
*
Email:
*
Confirmation Email
example@example.com
Vision Considerations
Is your child blind or have low vision?
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Yes
No
Are you concerned with your child's vision?
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Yes
No
If so, why:
Has the child been referred to, evaluated, or under the care of an optometrist (eye doctor)?
*
Yes
No
If yes, location name:
Date Tested:
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State
Zip
Have you noticed any of the following? Does your child: (Check all that apply)
Have an eye that turns up, down, in, or out independently of the other eye
Use eyes to follow a moving target held approximately 10 or 12 inches in front of them
Blink excessively/Rub eyes frequently
Favor one eye over the other
Fall frequently or bump into objects or furniture
Frequently hold things very close to their face to see them
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Hearing Considerations
Is your child deaf or hard of hearing?
*
Yes
No
Are you concerned with your child's hearing?
*
Yes
No
If so, why?
Has the child been referred to, evaluated, or under the care of a doctor for hearing concerns?
*
Yes
No
If yes, location name:
Date Tested:
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State
Zip
Does your child usually: (Check all that apply)
Respond to name or interesting noise if not already looking at caller
Respond when given simple directions
React to loud or unexpected noises (i.e. flinch or cover ears)
Notice and/or imitate environmental sounds (i.e. dog barking, a plan overhead)
Is there a medical history of infections, tubes, wax build-up, etc.?
*
Yes
No
Additional Comments:
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Upload any relevant information:
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Click "Submit" to complete the form.
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