*
Required
To refer a child please complete the form below. Once it has been completed and submitted our office will contact you to set up an appointment.
Child Information
Referring Agency
*
required
Referring Agency Phone:
*
required
Referring Agency Contact Person
Referring Agency Contact Person Phone:
County of Residence *
Duval
Clay
Nassau
Child's Last
*
required
Child's First
*
required
Middle
Date of Birth (Child Must be 3 to 5 years of age not enrolled in a public school)
*
required
(mm/dd/yyyy)
Male/Female*
Male
Female
Race
Please Select…
African American/Black
Asian
Native Hawaiian or Other Pacific Islander
White/Caucasian - Non Hispanic
Other
Birth City/State:
Preschool / Child Care Provider:
Parent Guardian Information
Child Lives with:*
Both Parents
Mother
Father
Foster Parent
Guardian
Mother First and Last Name:
*
required
Mother Cell Phone
*
required
Can we text this number (SMS rate may apply)
Yes
No
Email Field
Are you a member of the Military?
Yes
No
Father First and Last Name:
*
required
Father Cell Phone
*
required
Can we text this number (SMS rate may apply)
Yes
No
Are you a member of the Military?
Yes
No
Foster Parent First and Last Name
*
required
Foster Parent Cell Phone
*
required
Can we text this number (SMS rate may apply)
Yes
No
Guardian First and Last Name
*
required
Guardian Cell Phone
*
required
Can we text this number (SMS rate may apply)
Yes
No
Is there a Termination of Parental Rights (TPR)?*
Yes
No
Are you a member of the Military?
Yes
No
Mailing Address 1
*
required
City
*
required
State
*
required
Zip
*
required
Language(s) Spoken in home if other than english?
Yes
No
What Language(s)?
Will an Interpreter be needed?
Yes
No
Is there a case worker?
Yes
No
Name of Case Worker:
Case Worker's Phone
Please select the reason you want to refer your child:
Check all that apply:*
SPEECH (hard to understand, talking is not clear)
EXPRESSIVE LANGUAGE (few words in vocabulary, doesn't put many words together)
RECEPTIVE LANGUAGE (doesn't seem to understand, difficulty following directions)
SOCIAL EMOTIONAL (interactions w/others, social skills)
Development (seems behind, difficulty retaining information)
SELF HELP (independent, functioning, toileting, feeding, dressing)
HEARING
VISION
FINE MOTOR SKILLS (holding, drawing, grasping, picking up small objects)
GROSS MOTOR SKILLS (clumsy, falls a lot, poor coordination or balance)
BEHAVIOR (aggressive, harms self or others, inattentive, active)
Previous Testing
Yes
No
Where was the testing done?
Location of the testing site?
Medical Diagnosis
Yes
No
What is the diagnosis
Receiving any Developmental Service (Check all that apply)
Speech and Language
Occupational Therapy
Physical Therapy
Behavior (ABA Therapy)
Who is the provider of the service:
Please send a confirmation email to the address below:
Please provide an email address where we can send a link to your current form.
Email Address :