DCSD Child Find Intake Form

Thank you for helping us understand your concerns by completing this form. All of the information is important to us. Once we receive the completed form, you will be contacted within two business days to schedule an appointment. 



Items denoted with a red asterisk * are required.
 
 
 
 * Student First Name
 
Student Middle Name
 
 * Student Last Name
 
 * Student Birthdate
 
Click to View Date Picker
 * Student Gender
 
 * Parent/Guardian 1
 
Parent/Guardian 2
 
 * Address
 
 * City, State, Zip
 
 * Home Phone
 
 -  - 
Cell or Work Phone
 
 -  - 
 *  
 
What is your main concern that brings you to Child Find?
 *  
 
What is your relationship to your child?
 *  
 
Primary language spoken by parents in home
 *  
 
Primary language spoken by child in the home
 
 
The following information will help us in scheduling and planning the most appropriate appointment for your child. Please answer all questions fully.
 
 
 
 
 
COMMUNICATION
 
 
 
 *  
 
Please describe any concerns about your child's hearing:
 *  
 
Is your child's speech difficult to understand?
 *  
 
Please describe any concerns about your child's speech:
 *  
 
Approximately how many words are in your child's vocabulary?
 *  
 
How does your child let you know (s)he wants something?
 *  
 
Give a few examples of a typical phrase/sentence:
 *  
 
What directions will your child follow?
 *  
 
If your child is excited about something, how will (s)he let your know?
 
 
 
 
 
MOTOR DEVELOPMENT
 
 
 
 *  
 
Do you have any concerns with your child's vision?
 *  
 
Please describe any concerns with your child's gross motor skills (crawling, walking, coordination, etc.):
 *  
 
Please describe any concerns about your child's fine motor skills (holding/using utensils, markers, etc.):
 
 
 
 
 
PLAY
 
 
 
 *  
 
Give examples of how your child likes to play:
 
 
 
 
 
SOCIAL INTERACTION
 
 
 
 *  
 
Describe your child's interaction with other children:
 *  
 
Please describe any concerns you have with your child's behavior?
 
 
 
 
 
PREVIOUS TESTING
 
 
 
 *  
 
List other evaluations, with dates, your child has had:
 *  
 
Please list any other evaluations that are currently underway:
 *  
 
Who referred you/how did you discover Child Find?
 *  
 
If your child attends preschool or child care programs, please list here, or indicate none:
 *  
 
Please explain any concerns there have been in any aspect of a preschool/child care setting:
 
 
 
Daytime Phone
 
 -  - 
Please provide the best number for us to reach you at during business hours.
 
 
 
Ethnicity
 
 
 
 
E-mail Address