Dear Child Development Specialist/Health Provider,

On ______________, we saw ______________________________, age ___________ , d.o.b. _________ parents’ names(s) ______________________________________ Phone:_________

Address _________________________________________________________

We viewed _____________’s development using:

__screening tools including (list measures)__________________________________________ __assessment tools including (list measures)_________________________________________

__diagnostic measures including: _________________________________________________

            _________________________________________________________________________

The results suggest significant challenges in these areas:

    __fine motor skills

    __receptive language

    __expressive language and articulation

    __gross motor skills

    __self-help skills

    __social-emotional-behavioral/mental health skills

    __preacademic and academic skills

    __chronic illness or other conditions associated with developmental-behavioral             problems (list): _______________________________________________

We have responded by:

    __giving parents information on things to do at home

    __screening hearing, vision, and lead levels: results _______________________

    __scheduling a follow-up visit to address _________________________________

    __explaining to parents the need for additional testing of _______’s learning,             development and behavior

    __recommending that ______________ receive additional evaluations (list medical             subspecialty, therapy or other specialized evaluation services: ___________________

            _________________________________________________________________________

We would like your program to:

    __contact this family to schedule an appointment

    __allow our office to schedule an appointment for this family

    __give parents information on things to do at home

    __provide parent training in developmental promotion

    __address issues in parent and child well-being

    __arrange for social services to assist with ____________________________________

    __administer more detailed measures of learning, development and behavior

    __assess specifically in the area(s) of________________________ in addition to your             usual assessments.

    __screen ______________’s __hearing, __vision, __lead levels, __health

We’ve asked the parents for permission to allow us to send and receive information so that we can keep track of additional evaluations, services and progress. The parents have signed below to show they are willing for information to be shared between our services.

                                                                                                _____________________________

                                                                                                Parent signature

Please keep us informed and up-to-date on your efforts with this child and family and how best to collaborate. We prefer to be contacted by:

__phone at ___________________. The best hours to reach us are _________________

__email   __fax __surface mail

Thank you,

____________________

Provider

Sample Summary Report for Parents

_____________  ________________  ________________________________________

date                           date of birth                           child’s name

Dear Parent(s),

During today’s visit, we looked carefully at how your child is learning, developing and behaving. ___________ seems to be doing well in:

    __using hands and fingers to do things

    __listening and understanding

    __talking and speech

    __using arms and legs

    __learning to take care of himself/herself

    __getting along with others and behaving

    __learning preschool and school skills

We had concerns about how he/she is doing in these areas:

    __using hands and fingers to do things

    __listening and understanding

    __talking and speech

    __using arms and legs

    __learning to take care of himself/herself

    __getting along with others and behaving

    __learning preschool and school skills

We would like to:

    __give you information on things you can do at home.

    __look at his/her learning, development and behavior more carefully

    __screen his/her hearing, vision, and lead levels

    __have _____________ seen by  __________________________, _________________

            for tests of _________________, _________________________

If there are difficulties, good help is available. Getting help early is wise. 

__We have made an appointment for ________________ at (time) __________________

    on (date) _________________ at (service)___________________________________

    located at _______________________________________ phone: ________________

    and also at (time) __________________ on (date) _________________

    at (service)___________________________________

    located at ________________________________________phone: _________________

__We ask you to make appointments for ______________ at (time) __________________

    on (date) _________________ at (service)___________________________________

    located at _______________________________________ phone: ________________

    and also at (time) __________________ on (date) _________________

    at (service)___________________________________

    located at ________________________________________phone: _________________

__This office would like to see you and ________________ in ___ month(s), and we’ll look             again at his/her __health, __learning, and progress.

If questions come up before then, please contact me at ___________________

Thank you,

____________________

Provider

On the next page, we show links to national services (parenting information, referral resources, etc.)