Family Screening Profile
Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
Did an agency refer you to screening or our program?
CFC (Child & Family Connections)
FHN Parent Enrichment Program
FHN Pediatric Rehab
DCFS (Department of Children & Family Services)
Local Health Department
If so please list agency and date
of services if applicable:
Does your child currently attend a preschool program (public or
Does anyone in your family have a history of drug or alcohol
Does your family have a history of physical violence?
Has your child ever lived outside the home for an extended time?
Does any household member have any serious illness or handicap?
Have any of your child’s siblings had difficulty in school?
Did either of your child’s parents have difficulty in school?
Does your child currently have a chance to play with others his/her
Has your family recently experienced
Other/ Additional Information:
Are you currently receiving:
Other Assistance or Support?
Medicaid/ ALL Kids
Childcare Subsidy Payments