Child Care Support Services Brief Screening Referral

Child/Family Information
Name of Child:	Date of Birth (yyyy-mm-dd):
Parent/Guardian Name:	Phone Number:
Mailing Address & Postal Code:
Preferred contact method: ☐ phone ☐ text ☐ email
Preferred language: ☐ English ☐ French ☐ other: if so, is interpreter required:
Concerns/Reason for screening: ☐ Speech/Language ☐ Social/Emotional ☐ Gross Motor ☐ Fine Motor ☐ Overall Development Any Other Concerns:
Parents/Guardian is aware of concerns and of screening process Yes ☐
Name of Child Care Program:
Days Child is Attending:
Has anyone suggested your child be screened other than the child care program: ☐ yes ☐ no Please specify:
Other services Involved: ☐ Children’s Centre Thunder Bay – Child & Family Counselling & Therapy ☐ Preschool Communication Services ☐ Dilico Anishinabek Family Care – Infant Child Development Program ☐ George Jeffrey Children’s Centre ☐ Other, please specify:________________________________________

Parent/Guardian Signature: ____________________ Date: _____________________

Child Care Supervisor Signature: _______________ Date: _____________________

Child Care Program provided family with Brief Screening information page Yes ☐