Early Childhood Special Education Referral FOR ADDITIONAL LANGUAGES, PLEASE USE DROP DOWN BOX TOWARDS THE RIGHT

Early Childhood Special Education Referral

This form is for children aged 3- 5 years old We appreciate you taking the time to fill out this form. It serves two important purposes: it's part of the referral process for your child, and it helps us gather important background information to better understand your child's needs. The form should take about 15-20 minutes to complete. Your insights are valuable to us as we work together to support your child's development. ** For additional languages, please select the drop down feature at the top of this form.**
Before proceeding, please ensure your child resides within the Snohomish School District boundaries, you can check using the School Site Locator below:

School Site Locator
Registration

As part of the next steps, the developmental screener team will complete an application for registration on your behalf. If you have any questions about this, please contact Amy Joynt directly at amy.joynt@sno.wednet.edu
Child's Name (First and last name)*

First NameLast Name
Child's Date of Birth *

MonthDayYear
Date
Child's Birth City and State
City, State
Child's Gender*

MaleFemaleNon BinaryPrefer Not to Say
What is the child's race? Mark one or more boxes*

WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderLatino/aOther
Child's Primary Language*

EnglishSpanishHindiKoreanGermanOther
Where is your child at during the day?*

HomeDaycare of PreschoolHead StartECEAPGrandparentsOther
Preschool or daycare name:
Preschool/daycare address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information*

First NameLast Name
Parent/Guardian*

MotherFatherGuardianFoster ParentOther
Best contact Number*
Please enter a valid phone number.
Email*
example@example.com
Address (City, State, Zip)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
At how many months was your child when they started crawling? *
At how many months was your child when they started walking? *
How many months was your child when s/he spoke their first word. *
How many months was your child when s/he combined more than one word. If they have not done these skills, indicate no. *
Are there any areas of your child's development that you're worried about? For example, do you have concerns about how they talk, play, learn, or interact with others? Please share any thoughts or observations you have.*
Is there any medically relevant information you'd like to share? *
Preferred Communication Method

PhoneEmailTextNo Preference
Reason for Referral

This information will assist us in getting to know your primary concerns and to best support you and your child.
Please summarize your concerns and reason for referral below.*
What are your child's strengths?*
Please check all the areas of developmental concerns below:*

Communication (do they understand you)?Articulation (how they make their speech sounds)Fine motorGross motorProblem solving skillsAdaptive (daily living skills)Social Skills/Problem BehaviorsHearing/VisionOther
Birth and Early Developmental History
Where there any complications or medical concerns during pregnancy, delivery or within the first six months?
Does your child have any medical diagnosis or conditions? If so, please include the name of the medical provider and any current medications for this condition.
Approximately when was your child's last well-child or doctor visit?

MonthDayYear
Date
Do you have any concerns regarding your child's vision?

YesNoMaybe
Do you have concerns regarding your child's hearing?

YesNoMaybe
Has your child's hearing or vision been screened by their pediatrician or a specialist in the past (audiologist or ophthalmologist/optometrist)? If yes, please share at what age.
Does your child currently see a specialist (OT/PT/SLP), counselor, or other medical provider on a regular basis?
If yes to the above, tell us more about the specialist/medical provider your child sees:
List any serious illnesses or injuries (include age of child and treatment received):
Do you have any concerns regarding your child's sleep routine? If yes, please describe your concerns.
Does your child have any known allergies? If yes, please explain.
Do you have any sensory concerns at this time? Is your child sensitive to sounds, lights, textures etc.? If yes, please describe your concerns.
Is there a family history of communication delay, learning disability, ADHD, or other condition that may impact student learning?
What are some of your child's interests? Do they have preferred toys, television shows or characters?
Is there any other information you feel it is important for the team to be aware of or consider?
Please schedule a time for our evaluation team to complete a screener- details below.
Have you scheduled your screening appointment using the embedded calendar? SEE ABOVE.*

Yes, I've scheduled my meetingNo, I need to schedule it.
Should be Empty:

Early Childhood Special Education Referral

Registration

Reason for Referral

Birth and Early Developmental History