Child Find Screening

Child Find Screening

Child Find Screening Request

  • Student Name

​   FirstLast

  • Student Date of Birth:

    ​MM/DD/YYYY

  • Students Age:

3

4

5

My child has not yet reached their 3rd birthday, but I am interested in discussing the steps that could be taken when they turn 3

  • Home Street Address:

​    

At least one parent or guardian must be a current resident of Hudson, NH for a child to be screened.

  • Home Phone: 

   

  •  Parent/Guardian Full Name:

   ​ Cell Phone: 

  • Parent/Guardian Full Name:

   Cell Phone:  

  •  Parent/ Guardian Email

 

  • Child lives with:

  • Child's Primary Language:

  • Did someone other than yourself recommend you have your child screened? 

  • Does your child have preschool/daycare experience?

Yes

No

  • School/Daycare Name:

  

  • Teacher Name:

  

 

Program Type:

Kindergarten

Preschool

Daycare

How many days did your child attend? 

Does your child attend full days or half days?

Full days

Half days

  • Describe your concerns in each of the sections below. Please type "None" if you do not have concerns in a certain area.

 

  • Speech and Language:

 Please describe any articulation concerns. Are there specific words or sounds that your child has trouble with?

  • Speech and Language:

Please describe any language concerns. Does your child have trouble understanding words when spoken to or trouble putting words together to form sentences?

  • Academic/Learning: 

  • Social/Behavioral:

  • Motor:

Please describe any fine motor concerns. Does your child have difficulties using hands and fingers to complete tasks such as coloring and picking up objects?

  • Motor:

Please describe any gross motor concerns. Does your child have difficulties using arms and legs to do whole body activities such as walking, jumping, and crawling?

 

  • Please describe any other concerns you have about your child:

  • Please share any other information you feel we should know about your child:

 

 

 

 

 

 

 



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