Fillable Preschool Child Find Questionnaire (Montgomery Schools)

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Preschool Child Find Questionnaire (Montgomery Schools)

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MCPS Form 335-49
January 2019
Page 1 of 2
Preschool Child Find Questionnaire
MONTGOMERY COUNTY PUBLIC SCHOOLS
Office of Special Education, Child Find
English Manor Center, 4511 Bestor Drive, Room 146, Rockville, Maryland 20853
Telephone 240-740-2170, Intake 301-947-6080, Fax 301-871-0957
INSTRUCTIONS
To be eligible for screening, evaluation, and services, the child must enroll in Montgomery County Public Schools (MCPS) pursuant to Montgomery
County Board of Education Policy JEA, Residency, Tuition, and Enrollment, and provide evidence of the child’s birth (i.e. birth certificate, passport/visa,
physician’s certificate, baptismal or church certification, hospital certificate, parents’ affidavit, or birth registration), and proof of residency pursuant
to MCPS Regulation JEA-RB, Enrollment of Students, (current property tax bill, current lease (if lease is more than 1 year old, lease and currently utility
bill), or MCPS Form 335-74, Shared Housing Disclosure). For a nonresident child attending preschool in Montgomery County, the parent/guardian
must provide verification of the child’s enrollment on the preschool’s letterhead.
To complete the preschool process for children who will be eligible for kindergarten the following school year, this questionnaire must be
received in the Child Find office by the last Monday in March of the year that your child will be eligible for kindergarten. After that date,
please contact your local elementary school to complete the screening process.
STUDENT INFORMATION
Must match birth certificate or other evidence of birth
Legal last name
________________________________________ Legal first name____________________ Legal middle name____________________
Student’s address ________________________________________________________________________________________________________________
Medical Assistance eligible? o
Yes o No Date of Birth _____/_____/______ o Male o Female
Was the student born outside of the United States? o
Yes o No If Yes:
How many months has the student attended U.S. schools?
______
Language(s) spoken at home
___________________________________________________________________________________________________
ADULT(S) RESPONSIBLE FOR STUDENT*
Name of adult responsible for student living at current address:
___________________________________________________________
Relationship:
o Mother o Father o Guardian
  o Other (Specify)
__________________________________________
Phone #1 _____-_____-______ Phone #2 _____-_____-______
* Responsible adult(s) legal identification and proof of relationship
to student verified (please specify)
__________________________________________________________
Name of adult responsible for student living at current address:
___________________________________________________________
Relationship:
o Mother o Father o Guardian
  o Other (Specify)
__________________________________________
Phone #1 _____-_____-______ Phone #2 _____-_____-______
* Responsible adult(s) legal identification and proof of relationship
to student verified (please specify)
__________________________________________________________
PARENT SURVEY
What concerns do you have about your child?
_______________________________________________________________________________
Was your child ever referred to the Montgomery County Infants and Toddlers Program? o Yes Month______ Year _________ o No
How were you referred to Child Find? o Family o Flyer o Friend o Physician o Teacher o Other ________________________________
Has your child ever been assessed? o Yes (please attach reports and complete below) o No
Dates assessed:_____/_____/______ _____/_____/______ _____/_____/______Testing location: ___________________________________
Reason: _______________________________________________________________________________________________________________
Child attends: o Preschool o MCPS PreK/Head Start o Day Care o Home Day Care o Home o Other ___________________________
Name of preschool/day care: ______________________________________________________________________________________________
Address of preschool/day care: ____________________________________________________________________________________________
If preschool/day care has concerns, please explain:
FOR OFFICE USE ONLY
Date of Call: _____/_____/______ MCPS ID# ________________________________________________ Date Call Returned/Scheduled _____/_____/______
By Whom
_______________________________________________________________ CA_______________________________Clinic Date _____/_____/______
Location
__________________________________________________________________________________________________ Time_______________________
Home School
_____________________________________________________________________________________Cluster_______________________________
MCPS Form 335-49
Page 2 of 2
MEDICAL INFORMATION
Authorized Health Care Provider name
____________________________________________________________________________________
Any difficulties o before o during o after the birth of your child?
If yes, please elaborate:
Hospitalizations: o serious illness o accidents o surgeries
Please explain:
List any medications your child takes on a regular basis (include dosage):
______________________________________________________
Please list any allergies: __________________________________________________________________________________________________
Hearing concerns? Explain _______________________________________________________________________________________________
Vision concerns? Explain _________________________________________________________________________________________________
Check all area(s) of concern/possible delay
o does not appear to be learning at an average rate
o delays in developmental milestones
o other ____________________________________________________
SPEECH/LANGUAGE
o began to talk at ______ months
Speech is difficult to understand
o parents understand _____%
o others understand _____%
o stutters/dysfluent
o often needs directions/questions repeated
Communicates by
o gestures
o single words
o phrases
o sentences
o other ____________________________________________________
MOTOR
o bumps into things
o trips and falls often
o fearful on the playground
o unusual reaction to touch
o unusual reaction to sound
o unusual reaction to light
o problems with paper/pencil tasks
o walked at ________________________________________________
o other ____________________________________________________
ATTENTION
o easily distracted
o short attention span
o darts from one task to another
o difficulties with changes in routine
o other ____________________________________________________
SELF-HELP
Significant delays with
o feeding
o dressing
o toilet training
o other ____________________________________________________
SOCIALIZATION
o consistently shows no interest in playing/relating with others
o rarely looks at people
o becomes upset in group settings
o gets stuck on one idea, object, or activity and becomes upset if
requested to change
o appears to be in their own world
o other ____________________________________________________
BEHAVIOR
o tantrums
o is not able to accept limits
o refuses to comply with requests
o aggressive towards others
o easily frustrated
o other ____________________________________________________
Additional information
This form will be maintained in a confidential folder and access to the report(s) will be granted to MCPS staff on a
need-to-know basis. A record will be maintained documenting the name and reason for each reviewer. Parent(s)/
guardian(s) and eligible students may request/authorize release to another agency/professional.
Signature of Parent/Guardian:
______________________________________________________________________ Date:_____/_____/______
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Completed 15 November 2021

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