* Required

To refer your 3 to 5 year-old 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

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/BlackAsianNative Hawaiian or Other Pacific IslanderWhite/Caucasian - Non HispanicOther

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*required

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 for the Parent/Guardian?

Yes  No 

Will an Interpreter be needed for the Child?

Yes  No 

Is there a case worker?

Yes  No 

Name of Case Worker:*required

Case Worker's Phone*required

Please select the reason you want to refer your child (as compared to other children at the same age):

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 ( has poor interactions w/others, social skills)  Development (seems behind, difficulty retaining information)  SELF HELP (has issues with independent, functioning, toileting, feeding, dressing)  HEARING  VISION  FINE MOTOR SKILLS ( has difficulty holding, drawing, grasping, picking up small objects)  GROSS MOTOR SKILLS (is clumsy, falls a lot, poor coordination or balance)  BEHAVIOR (is aggressive, harms self or others, inattentive, active) 

Who reffered you to Child Find for a screening?

Pediatrician  Private Speech and Language Pathologist  Private Behavioral Health Organization  Family Friend  Web search  Other 

Please provide the name of the Doctors office or Private Agency

Please describe who refered you.

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: