SCREENING APPLICATION

Please answer all questions below. This form is used to assist us in gathering information about your child in order to be registered into the medical records system and to best prepare for the assessment process.

Child Name

Date

Gender

Grade

Child's Age

Home Address

City

State

ZIP

County

Home Phone

Cell Phone

Work Phone

Email Address

Language Preference

Interpreter Needed?

English Fluency

Referral Information Briefly describe the reason(s) you contacted Mississippi Center for Autism and Developmental Disabilities (MCARDD):

Who referred you to MCARDD?

Title

Phone

FAX

Address

5 + 1 =

Mississippi Centers for Autism and Related Developmental Disabilities

Turning Disabilities Into Possibilities One Day at a Time.

SCREENING APPLICATION