Loudoun County Public Schools
Child Find Screening Appointment Request
Student First Name:
Student Last Name:
Parent First Name:
Parent Last Name:
Street Address:
City, Zip:
Student DOB:
Primary Phone:
Email:
Referral Information
Referral Source:
Parent
PreSchool Teacher
Doctor
Other(Specify)
Other Description
Reason for concern:
Description of concern:
Name of Babysitter, Day Care Provider, or Preschool:
Have there been any previous evaluations?
Yes
No
What type(s) of evaluation?:
When:
Where:
Please bring copy of any previous evaluation(s) to the screening appointment.
Language History
Does your child hear or understand any language(s) other than English?
Yes
No
What language(s)?/what country?
Does your child speak any language(s) other than English?
Yes
No
What language(s)?/what country?
What language does the babysitter use to communicate with the child?
English
Other(Specify)
Other Description
* Required Fields