CDS Child Find Intake Form

Child Information

 (last, first)










(both parents, mother, father)

Interpreter needed?


*Does this child attend childcare or preschool?



*Are any other agencies working with this child or family?



Parent / Guardian 1 Contact Information

Contact information for at least one parent or guardian is required.
This information is for the person(s) with whom the child resides.

  (last, first)






Relationship to the child


Parent / Guardian 2 Contact Information

  (last, first)



Parent/Guardian 2 Mailing Address  



Relationship to Child

Are the parents/guardian aware of this referral? 



Primary Healthcare Provider





Referral Source Information

Please fax any supporting documentation, such as evaluation reports or progress notes, at the time of the referral to 207-624-6661.

  (last, first)






Referral Source's Relationship to Child 
Reason for Referral

Area(s) of Concern: (check all that apply)