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SCREENING INFORMATION SHEET
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* Indicates required question
Email
*
Your email
Does your child currently attend preschool?
*
YES
NO
Required
If yes, where?
Your answer
Were you referred by MCKIDS?
*
YES
NO
Required
Childs Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Male or Female
*
Male
Female
Street Address:
*
Your answer
City, Stat, Zip:
*
Your answer
Mother's Name:
*
Your answer
Phone Number:
*
Your answer
Father's Name:
*
Your answer
Phone Number:
*
Your answer
What Concerns do you have:
*
None
Speech
Hearing
Vision
Motor Skills
Behavior
Mental Health
Other:
Required
What type of screening does your child need?
*
Full Developmental Screening
Hearing recheck
Vision
Hearing and Vision Only
Required
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