Child Find Intake Form

Child Information

Today's Date
    Date of Birth   
(09-01-2012)
Physical Address   Address 2   Gender
City   State   Zip

 


(207-123-4567)


Mailing Address Address 2

City   State   Zip  

Relationship to Child


 

Parent/Guardian Contact Information 2

 
(207-123-4567)

Same as above
Mailing Address Address 2  

City   State   Zip

Relationship to Child


Other  
Are the parents/guardian aware of this referral? If not, why? 

Primary Health Care Provider

Name Telephone (207-123-4567)
Practice Name

Referral Source Information

or 207-624-6661.

  Telephone (207-123-4567)
Agency

Email
Confirm Email Address
(A confirmation email will be sent to the email address provided)

Referral Source's Relationship to Child

Childcare
Head Start
Public School Program		 DHHS
Physician
Hospital
Practitioner of the Healing Arts
Other (specify)

Reason for Referral / Area(s) of Concern
Select all that apply
All Developmental Areas

Speech and Language
Hearing
Vision
Cognitive
Gross Motor
Fine Motor
Social / Emotional
Adaptive / Self-Help

Child Abuse Prevention and Treatment (CAPTA)
Autism
Other (specify)

Explanation of concern(s)

 

Diagnosis (if any)

Is this referral the result of a screening by

Maine Newborn Hearing Program?

Maine Newborn Bloodspot Program?

Maine Birth Defects Program?

Please list any other agencies working with this child and/or family.