*
Required
FDLRS Springs Child Find Referral
Referral Information
Residence County*
Alachua
Citrus
Dixie
Gilchrist
Levy
Marion
Date of Referral
*
required
(mm/dd/yyyy)
Referring Person
*
required
Agency
Phone (xxx-xxx-xxxx)
*
required
Check All Areas of Concern*
Learning
Speaking
Behaving
Seeing
Walking
Listening
Sensory Issues
Other
Comments on Areas of Concern:
Does your child have a medical diagnosis (from a doctor)?
Yes
No
If you selected yes, please list your child's diagnosis:
Has your child had any previous evaluations?
Yes
No
If you selected yes, please explain
FDLRS Springs Child Find Referral Continued
Child Information
Child's Last Name
*
required
Child's First Name
*
required
Middle
Child's Date of Birth
*
required
Gender*
Male
Female
Race (Check All That Apply)*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Parent Declines
Ethnicity*
Hispanic
Non- Hispanic
Child's Primary Language
Parent's Primary Language
Family Information
Parent/Guardian Name
*
required
Relationship to the Child
*
required
Mailing Address
*
required
City
*
required
Zip
*
required
Street Address
*
required
If different than mailing address
Best Phone
*
required
Second Phone
Email
FDLRS Springs Child Find Referral Continued
Current Services
Child Care Facility/School
Is your child receiving therapy?
Yes
No
If you selected yes, please explain
Any Additional Information