Crisp County School System

CRISP COUNTY SCHOOL SYSTEM

Child Find Referral

A Child Find referral can be made by parents, caregivers, health providers, etc. for children ages 3 – 21 who may be in need of Special Education Services.

1. Birth Certificate Name of Child: ______

Name Called By: ______DOB: ______

Sex: ______Race: ______Age: ______

Social Security Number: ______

Street Address ______Phone ______

2.  Parent(s)/Guardian(s) ______

Child lives with ______

3.  Agencies Serving the Family (DFCS, Headstart, Other) ______

4.  Child's Primary Care Physician ______

Address ______Phone ______

5.  The following information is essential. Please provide information about the student for all items to the best of your ability. Be especially careful to describe the primary area(s) of difficulty. Attach a separate sheet if needed.

*Please note if a Speech/Language Referral has also been completed.*

Behavior
Cognitive
Language*
Speech*
Motor
Sensory
Adaptive Skills
Socialization

List any on-going medical problems, parent concerns, and teacher concerns. Also, list any types of evaluations previously completed (include name, address, and phone # of evaluator). Use back if needed.

Interventions attempted prior to Child Find Referral:

Interventions: / Outcomes of interventions:
1.
2.
3.
4.

______

Signature of Referral Source/Date Parent/Guardian Signature

Send to:

Program for Exceptional Children

PO Box 729

Cordele, GA 31010-0729

Phone 229 276 3445 Fax 229-276-3406

REVISED 1/14/2015 Page 1 of 1