Permission to Screen 
Your child’s free developmental screening will measure skills in the areas of vision, hearing, expressive & receptive language, gross and fine motor, self-help, social/emotional development and cognition. A screening does not measure mental age or IQ, nor will it diagnose a child. Results of the screening will indicate whether or not, on this particular day, your child can perform skills at his/her current age level. Please keep in mind that all children develop at a different rate.
The location the screening will be conducted at? *
If "other" was indicated above, please indicate the name of the daycare or preschool your child is attending.
Child's Name *
Gender *
Date of Birth *
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What is your child’s primary language?
 *
If "other" was indicated above, what is your child's primary language?
Name of Caregiver(s) *
Biological mother’s name (if different from above):
Biological father’s name (if different from above):
Home Address *
City, State, Zip *
Home/Cell Phone # *
Email *
Please check the racial/ethnic identity of your child
 *
Required
All developmental domains will be screened (physical, adaptive/self-help, language, cognition, and social emotional). If you have additional concerns, please select from the following:
If you selected an area above, please describe your concern in detail below.
Does your child have any medical concerns or diagnoses?
 *
If yes, please explain
Was your child born 3 or more weeks premature? *
If yes, how many weeks premature?
Frequent ear infections *
If yes, time and duration of last ear infection?
Does your child currently have tubes in their ears? *
If yes, was the procedure within the last two weeks? *
Family genetic history of hearing loss? *
Family history of learning and/or speech/language difficulties? *
Does your child have vision complications? *
If yes, please describe in detail what the complications are?
Are they seen by an ophthalmologist? *
If yes, who are they seen by?
Do you have other children, under the age of five, that you would like to have screened? *
Do you have any other questions or concerns you would like the screener to be aware of? *
I understand that the state of Wyoming maintains a Screening Results Database. The benefits of the database are to ensure appropriate screening, follow-up and referral processes. Screening records are confidential and only accessible by authorized personnel. Records will not be released to other sources without my written permission. I understand that by signing this permission my child will be screened in the areas described above, but no future screenings or formal evaluation will occur without my written permission.

By clicking "I agree," you agree to allow the Sweetwater County Child Developmental Center to screen my child and share the screening results with my child's physician, eye doctor, or audiologist if necessary *
**Due to state and Federal regulation, we are obligated to provide screening information to Sweetwater County School District #1 and Sweetwater County School District #2 for tracking and accounting purposes.
Parent/Guardian Signature 
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Date *
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Next Step
If you have not already done so, please fill out the Self-Help / Social-Emotional scales forms for 2-year-olds, or 3–5-year-olds (click link before submitting). 
2-Year-Old Form
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