Get Child Development Center Appointment Intake Form

Completing the Child Development Center Appointment Intake Form is an important step in ensuring your child receives the appropriate evaluations and support. This guide will provide clear and detailed instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the document management system.
2. Start by entering today's date at the top of the form. This helps maintain a record of when the form was completed.
3. Indicate the referral source by filling in the name of the individual or organization that referred you to the Child Development Center.
4. Fill in your child's name and date of birth in the designated fields. Ensure that this information is accurate to avoid any scheduling issues.
5. Provide the parent's name and date of birth, noting any relevant information about the child's living situation, such as which parent is primarily responsible.
6. List contact information including home, work, and cell phone numbers. Providing accurate contact details will facilitate communication regarding appointment scheduling.
7. Fill in the home address, including city, state, county, and zip code. This information ensures the accuracy of your child's records.
8. Enter your child’s pediatrician’s information, including their name, address, and telephone number, which is essential for coordinated care.
9. Complete the insurance details for both primary and secondary insurance, including the subscriber's name, date of birth, and relationship to the insured. Attach a copy of the insurance cards as specified in the instructions.
10. Answer questions regarding your child’s previous evaluations and any concerns you may have about developmental issues such as autism, academic performance, and behavior.
11. Complete the sections related to your child's medical history and development milestones, ensuring to provide any relevant details about their health or previous treatments.
12. At the end of the form, include your signature and date to verify that the information provided is accurate and complete.
13. Save the completed form, then choose to download, print, or share it with the Child Development Center as per the submission guidelines.

Take the next step in securing your child's appointment by completing the Child Development Center Appointment Intake Form online.