Preschool Referral Request Form

Preschool Referral Request Form

Special Education Services
Child's Full Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
What is child's gender?*
Parent/Guardian Name*
Relationship to Child*

Biological ParentAdoptive ParentFoster ParentLegal GuardianOther
Phone Number*
Format: (000) 000-0000.
Parent Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / 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
What is your child's primary language? *
Ex. English, Spanish
Are there other languages spoken in the home besides English? If so, what are they?*
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 words10-25 words25-50 words50-100 wordsMore than 100 words
What mode best describes the majority of your child's communication?*

GesturesVocalizations/gruntingSingle Words2-3 word combinationsSimple sentences
Check all of the skills that your child typically demonstrates:*

Follows 1 step directionsFollows 2 step directionsResponds to his/her namePoint 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)?*

NoneEarly InterventionPrivate Speech TherapyPrivate Occupational TherapyPrivate Physical TherapyOther
Please upload any evaluation reports you would like to share.

e.g.: autism evaluation report, speech therapy evaluation report, occupational therapy evaluation report, etc.
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