Parent Request for Special Education Testing with Student Background Information

Child Find Request Form

Thank you for entrusting your child's care to the LBSD Student Services Department. The information collected on this form will be used by your child's school to help them determine your child's educational needs. Please answer all questions to the best of your knowledge or indicate the answer is unknown.
Student's School
Student's Home Room Teacher
Person Making the Request

First NameLast Name
Agency Represented
Requester's Email Address
example@example.com
Requester's Phone Number

Area CodePhone Number
Relation to the Child
Student's Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Age Band
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is any language other than English spoken in the student's home?
Parent/Guardian's Language
Child's Language
Who does the student live with?
Describe the student's strengths. These can be personal or academic.
Please describe any situational circumstances relevant to the student (recent divorce, custody disputes, financial hardship, trauma,
How many School Districts has the student been enrolled in over the past 3 years.
Over the past 3 years, has the student frequently been absent from school?
What was the reason for the student's absence from school?
Developmental History / Health
Were there any problems with the child's birth or during early childhood?
Describe any problems in birth or early childhood that may have impacted your child's development.
Has your child had any operations?
List the operation and the student's age at the time of the operation.
Has your child had any significant accident/injuries?
List the injuries and the student's age at the time of the injury.
Has the student ever received speech, occupational, or physical therapy?
List the therapy and the student's age while receiving therapy.
Does the student have a medical or mental health diagnosis for an ongoing condition?
List each diagnosis and the medical / mental health provider who treats the student.
Does the student take medication on a regular basis?
List each medication and dosage.
Educational / Cognitive
Does your child regularly need any of the following? Check all that apply.

Other
Indicate any areas that your child has difficulties with:

Other
Describe any difficulties the student has with thinking or learning activities
Has the student ever been evaluated/assessed/tested for learning difficulties?
Who evaluated the child, and what were the results of the assessment?
Adaptive
Select the items that the student CAN do independently

Other
Describe any difficulties the student has with daily living skills.
Communication
Do you have any concerns about the following. Choose all that apply.

Other
Describe any concerns about the student's speech/language skills
Social / Emotional / Behavioral
Indicate if the student has any of the following difficulties

Other
Describe any concerns about the student's ability to get along with peers.
Indicate if the child has any of the following difficulties

Other
Describe any concerns about the student's emotional functioning
Indicate if the student has had any of the following difficulties:
Describe any concerns you have about the student's behavior
What is the best time of day to contact you?
What is the best time of day to arrange a meeting with you?
Does the child attend a public/private school or preschool/childcare center?
Child's School
Preschool/ Childcare Center or Private School Name:
Preschool/ Childcare Center or Private School Phone Number:
Preschool/ Childcare Center or Private School Location:
Preschool/ Childcare Center or Private School Teacher:
Please describe, in detail, any concerns that you have for your child's development, behavior, and/or learning.
How did you hear about Child Find?
Should be Empty:

Child Find Request Form

Developmental History / Health

Educational / Cognitive

Adaptive

Communication

Social / Emotional / Behavioral