Micco Child Find Referral

Directions: Please complete the form below. Once submitted, a child find specialist will contact the child's parents/guardian to schedule a screening appointment. A referral from a doctor is not necessary. No insurance is required.

If the child you're referring is less than 34 months old, please contact Early Steps to make a referral.

Is the child you are referring enrolled in a Head Start Program? If YES, please contact your local Head Start program to request a screening.

If the child you're referring is 6 years of age or older, or is already enrolled in a public-school program, please reach out to the referral coordinator at the child’s school.

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 the Big Bend.

1. Name of person/agency making referral.

2. Person/Agency Email

example@example.com

3. Person/Agency Phone Number

4. Child's First and Last Name

5. Child's Date of Birth MM/DD/YYYY

6. Parent(s) Name

8. Parent Email Address

7. Parent Phone Number

9. Child's Residence Address

Child's County of Residence.

11. Child's Gender

13. Child's Race/Ethnicity

14. Primary Language Spoken In the Home

Is a translator needed for this screening appointment?

If you checked yes, what language will be needed?

example@example.com

15. Reason for Referral (please check all that apply)

Important Medical History of Diagnosis.

Please upload any pertinent reports, information, evaluation or records.

FDLRS Miccosukee Child Find Referral