Language
English (US)
Spanish (Latin America)
Screening Clinic Contact Form
If you prefer to contact our office directly please call 620-225-5177 Se Habla Español
Arrowhead West Infant Toddler Services Serves Children ages 0 to 3 years. If your child is ages 3-5 years of age please contact the SKACD #613 at 620-371-1061 to have your child screened.
Child's First Name
*
Child's Middle Initial
Child's Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Race (Select all that apply)
Alaska Native/American Indian
Asian
Black
Native Hawaiian/Pacific Islander
White
Ethnicity
Hispanic
Non-Hispanic
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Relationship to Child
*
Aunt
Father
Foster Father
Foster Mother
Friend
Grandfather
Grandmother
Legal Guardian
Mother
Sibling
Step Father
Step Mother
Uncle
Other
Parent/Guardian Phone
*
-
Area Code
Phone Number
Email
example@example.com
Primary Language Spoken in the Home
*
Interpreter Needed
*
Yes
No
What screening clinic location would you like to attend?
Please Select
Dodge City
Meade
Jetmore
Cimarron
Ness City
Kinsley
Ashland
Montezuma
Other
Do you have a developmental concern at this time?
Please Select
Yes
No
Please explain your concern.
How did you hear about our screening?
Family/Friends
Medical/Health Dept.
NICU
Education Agency (EHS/PAT)
Daycare/DCF/Foster Care
Social Media (Facebook, newspaper, flyer in community)
Thank you for your information. Someone will be contacting you soon to set up an appointment.
Submit
Should be Empty: