Preschool Referral Request Form
Special Education Services
Child's Full Name
*
First Name
Middle Name
Last Name
Child's Date of Birth
*
/
Month
/
Day
Year
What is child's gender?
*
Please Select
Male
Female
Parent/Guardian Name
*
Relationship to Child
*
Biological Parent
Adoptive Parent
Foster Parent
Legal Guardian
Other
Phone Number
*
Parent Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child currently attend a daycare/preschool? If so, where and how often?
*
Example: MMO at XYZ Church 2 days/week 9-1
Please list your reason(s) for referral. Describe any concerns you have in as much detail as possible.
*
Do you have any concerns for your child's vison? If yes, please explain.
*
Do you have any concerns for your child's hearing? If yes, please explain.
*
How many words do you estimate to be in your child's verbal vocabulary?
*
0-10 words
10-25 words
25-50 words
50-100 words
More than 100 words
What mode best describes the majority of your child's communication?
*
Gestures
Vocalizations/grunting
Single Words
2-3 word combinations
Simple sentences
Check all of the skills that your child typically demonstrates:
*
Follows 1 step directions
Follows 2 step directions
Responds to his/her name
Point to things you name around the room
Does your child have any diagnoses, medically or behaviorally? Please list.
*
e.g. Autism, ADHD, Cerebral Palsy, Epilepsy, etc.
Does your child currently receive any of the following services (check all that apply)?
*
None
Early Intervention
Private Speech Therapy
Private Occupational Therapy
Private Physical Therapy
Other
Please upload any evaluation reports you would like to share.
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e.g.: autism evaluation report, speech therapy evaluation report, occupational therapy evaluation report, etc.
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