Today’s Date:

Child’s Name: Date of Birth:

Parent’s Name: Home Phone:

Home School (School child will attend in Kindergarten):

Today your child will be screened to determine if there are possible delays in his/her development. This is only a screening. If any of the pathologists you meet today have concerns, you will be referred for a more complete evaluation to determine if your child is eligible for preschool special education services. You will visit each screening station sometime during your appointment today. When all the information has been gathered on your child an exit interview will be completed and you will receive the recommendations from today’s screening. If you have any questions, please ask one of the staff members. Here is what you can expect today:

Staff Initial

____     Case History--The case history form that you received in the mail
               will be reviewed with you.

____     Vision--A staff member will screen you child’s vision.         PASS / FAIL

____     Hearing--A staff member will screen your child’s hearing.   PASS / FAIL

____     Speech/Language--A speech/language pathologist will screen
              your child’s ability to understand and use language including
              production of speech sounds.                                          PASS / FAIL

____     Concepts--A preschool pathologist  will screen your child’s
              reasoning and  problem solving skills as well as various
              pre-academic skills such as counting, sorting, colors, etc. PASS / FAIL

____     Motor--A preschool pathologist will observe your child’s motor
              skill by having them participate in typical preschool motor activities.
                                                                                                    PASS / FAIL
                                                                                                         
____     Exit Interview--A staff member will review the results of your child’s
              screening and make any necessary recommendations.

Recommendations:

Further Assessment:                                                   YES / NO

Permission to evaluate signed and parent has received a copy along with written notice and procedural safeguards:              YES / NO  
prescfm  7/2000