Child Find Intake Form

Full Legal First Name of Child*

Full Legal Middle Name(s) of Child - type NMN if the child does not have a middle name*

Full Legal Last Name(s) of Child *

Child's Date of Birth - Please note that we can only accept referrals for children who are 2 years, 9 months and older *

Child's Gender*

Male Female

Child's Ethnicity: Hispanic/Latino?*

Yes No

Child's Race:*

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Language(s) spoken in the home:*

Would you like an interpreter present at the screening meeting?*

Yes No

Please indicate type of interpreter needed:

Has this child previously been referred to Child Find?*

Yes No

Name of Person completing this form:*

First Name

Last Name

Email of Person completing this form*

Who is completing this form? *

Parent/Legal Guardian Frederick County Infants & Toddlers Head Start Doctor's Office The Judy Center Department of Social Services

Please note that Child Find may only accept referrals from the above.

Proof of Child's Date of Birth - Please select one of the following to upload:*

Birth Certificate Physician's Certificate Baptismal/Church Certificate Parent's Affidavit Passport/Visa

If you are unable to upload any of the documents above, please contact our office at 301-644-5292 .

Birth Certificate*

No File Chosen

File uploads may not work on some mobile devices.

Physician's Certificate*

No File Chosen

File uploads may not work on some mobile devices.

Baptismal/Church Certificate*

No File Chosen

File uploads may not work on some mobile devices.

Parent's Affidavit*

No File Chosen

File uploads may not work on some mobile devices.

Passport/Visa*

No File Chosen

File uploads may not work on some mobile devices.

What type of referral is this?*

WHICH STAFF TO INVITE TO MEETING:

First Name

Last Name

WHICH STAFF TO INVITE TO MEETING:

First Name

Last Name

WHICH STAFF TO INVITE TO MEETING:

First Name

Last Name

WHICH STAFF TO INVITE TO MEETING:

First Name

Last Name

Current I & T services the child is receiving:

OT SLP Educational

Other:

This completed referral is being sent with the following documents:

Initial Eligibility Evaluation (IEE) Report

IEE Report

No File Chosen

File uploads may not work on some mobile devices.

This completed referral is being sent with the following documents:

Individualized Family Service Plan (IFSP)

IFSP

No File Chosen

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This completed referral is being sent with the following documents:

Other

Other Attachment

No File Chosen

File uploads may not work on some mobile devices.

Does the child have Medical Assistance?*

Yes No

Please provide the 11 digit number that appears on the child's insurance insurance card:

Parent/Caregiver 1*

First Name

Last Name

Parent/Caregiver Type:*

Mom Dad Grandparent

Other:

Parent/Caregiver Phone:*

Parent/Caregiver Email:*

Home Address - Please note that this intake form is only intended for residents of Frederick County, Maryland*

Address Line 1

Address Line 2

City

State

ZIP Code

Residence School (Where the child will attend based on their physical home address):

If this child is eligible to attend Kindergarten in August 2024, the Child Find Process will occur at the Residence School. Please contact the residence school to make a referral.

To locate your neighborhood school, please use the following School Finder tool:

https://www.fcps.org/student-services/find-your-feeder-area1

Parent/Caregiver 2

First Name

Last Name

Parent/Caregiver 2 Type:

Mom Dad Grandparent

Other:

Parent/Caregiver 2 Phone:

Parent/Caregiver 2 Email:

Parent/Caregiver 2 Address:

Address Line 1

Address Line 2

City

State

ZIP Code

What are the concerns about early learning? *

Type N/A in the space above if Not Applicable

What are the concerns regarding speech/language (speech intelligibility, expressing wants and needs, following directions, responding to name, use of eye contact, etc.)?*

Type N/A in the space above if Not Applicable

What are the concerns regarding behavior (following routines, coping with changes in routine, activity level, attention, managing transitions, accepting limits, etc.?)*

Type N/A in the space above if Not Applicable

What are the concerns regarding social development (interactions with peers or siblings, playing with others, playing with toys, etc.)?*

Type N/A in the space above if Not Applicable

What are the concerns regarding mobility or gross motors skills (walking or running safely, safe play on playground equipment, etc.)?*

Type N/A in the space above if Not Applicable

What are the concerns regarding feeding, sensory, or fine motor skills (chewing and swallowing; using feeding utensils; over-or-under responsiveness to sounds, touches lights smells, or tastes; picking up and manipulating small objects; etc.)?*

Type N/A in the space above if Not Applicable

Do you have any concerns regarding this child's hearing?*

Yes No

Do you have any concerns regarding this child's vision?*

Yes No

What are any additional concerns?*

Does your child have any medical diagnosis?*

Yes No

Please describe:

Do you have assessments completed by other agencies?*

Yes No

Please upload assessment here:

No File Chosen

File uploads may not work on some mobile devices.

Please upload assessment here:

No File Chosen

File uploads may not work on some mobile devices.

Please upload assessment here:

No File Chosen

File uploads may not work on some mobile devices.

Please upload assessment here:

No File Chosen

File uploads may not work on some mobile devices.

Do you suspect this child has autism?*

Yes No Unsure

What about the child's behavior makes you concerned about potential autism?*

Is the child in private treatment (speech, etc.)?*

Yes No

If the child is currently in private treatment, please check all that apply:*

Speech Occupation Therapy Physical Therapy Applied Behavioral Analysis Counseling

Other:

Please describe where and when the child receives treatment:*

Does the child attend a community preschool? *

Yes No

Please list the name and address of the preschool:*

Please list the specific days and times your child attends preschool:*

Do we have your permission to invite a representative from your child's preschool to attend the screening meeting?*

Yes No

If "Yes" is selected, please let your child's preschool know that they will be contacted by Child Find.

Please provide the name of the person from your child's preschool that you would like to attend the screening meeting (if available):*

Please provide an email address for your child's preschool:*

Please provide a phone number for your child's preschool:*

Does the child attend an in-home daycare?*

Yes No

If applicable, name of school you submitted a Pre-K application to:

The screening meeting will occur in-person with you and your child at the Child Find Office located at 250 Madison Street, Frederick, MD, 21701.

By typing my name below, I certify that, to the best of my knowledge, the provided information is true and accurate and will be used for the purposes of scheduling a screening meeting for my child.

First Name

Last Name

For information pertaining to the Special Education Process, please see the link below:

Maryland Procedural Safeguards

Invite to screening meeting:

OT PT Psychologist Hearing Vision Interpreter

Notes:

name of school you submitted the Pre-K application to: