Child Find Intake Form

*Indicates a required field

Child Information

*Date of Birth (mm/dd/yyyy)

*Gender

Address

*Street Apt. #

*City   *State   *Zip


(both parents, mother, father)

*Language spoken at home

Interpreter needed? Yes  No

*Does this child attend childcare or preschool? Yes  No

If yes, name of childcare/preschool

Scheduled days

*Are any other agencies working with this child or family?
Yes  No

If yes, please list

Contact information for at least one parent or guardian is required

(last, first)

Email

(207-123-4567)

*Mailing Address

Street or P.O. Box Apt. #

City   State   Zip  

*Relationship to the child


(specify)

Parent / Guardian 2 Contact Information

(last, first)

Email

(207-123-4567)


Mailing Address Same as child

Street or P.O. Box Apt. #

City   State   Zip

Relationship to Child


(specify)

Are the parents/guardian aware of this referral?

If not, why? 

Primary Healthcare Provider

Name

Practice Name

Telephone (207-123-4567)

Fax (207-123-4567)

Referral Source Information

or 207-624-6661.

(last, first)

Agency


*Telephone (207-123-4567)

Fax (207-123-4567)


*Email

*Referral Source's Relationship to Child
Friend
Childcare Provider
Head Start
Public School Program
Primary Healthcare Provider
Hospital
Therapist
DHHS
Other (specify)

Reason for Referral

*Area(s) of Concern: (check all that apply)
All Developmental Areas (includes 6 following areas)

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

Autism
Behavior
Child Abuse Prevention and Treatment (CAPTA)
Drug Affected Baby
Hearing
Prematurity
Vision
Other (specify)

*Explanation of concern(s)

 

Diagnosis (if any)