Request Individual Screening

• Child's Name :
• DOB :
• Parent's Name :
• Home Phone Number :
• Cell Phone Number :
• Address :
• City :
• County :
• State :
• Zip :
• Date of screen :
• Name of pre-screener :

• Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

I would like to request further screening for my child. Please contact me at the number(s) listed above.

Area(s) of Concern :

Please mark any services below that you are receiving

• Childcare Services
• Child Care Assistance
• CHIP Children's Health Insurance Program
• Medicaid
• Early Head Start/Head Start
• South Dakota Cares
• Family Support Program
• Home Health Care
• Children's Health KICC
• Medical Insurance
• Mental Health Counseling
• Parenting Classes
• Preschool Services
• Respite Care
• SSI
• Support Groups
• Parent Connection
• Shriners'
• Community Agency Assistance
• Others (list)

Did you complete our online pre-screening?

• Yes
• No

Did our online pre-screening refer you to contact us?

• Yes
• No

Please select the representative nearest you :

If you do not live in the counties listed below please call
1-800-305-3064 for contact information to find your local Service Coordinator.

• CJ Moit-Mitchell: Lyman, Hughes, Stanley, Haakon, Sully, Hyde
• Stephanie Krusemark: Brookings, Miner, Lake, Moody
• Kelly Bradberry: Codington, Day, Marshall, Grant Clark, Roberts, Hamlin, Duel
• 
  

• 
  (Initial Service Coordinator Signature)
• 
  (Date Received)