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The Clinical Center for the Study of Development & Learning UNC Center For Development & Learning

Child Contact Form
(Please fill this form out using Internet Explorer 6.0 or later)

While we are eager to help to you and your family, we currently have a waiting list for services. For that reason, there is a possibility that we may not be able to evaluate every individual referred to the CDL as quickly as we would hope. In this event, you may want to contact your child's primary care physician about alternatives.

Child Information
Child's Name   
(First, Middle, Last)
Gender
Nickname
Age
Date of Birth
MM/DD/YY		 Grade
Street Address
City, State Zip ,
County
Child Lives With Parent/Guardian(s) Name(s)
Relation
Marital Status

Legal Custodian(s)
Primary Contact Person
Full Name Relationship to Child
Home Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format		 Work Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format
Cell Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format 		Email

Secondary Contact Person
Full Name Relationship to Child
Home Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format 		Work Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format
Cell Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format 		Email

Child's School
School Name County
Street Address
City, State Zip ,

Referral Source
Person Completing this Form Relationship to Child
Referred to CDL by Relationship to Child
If referral source is an agency or clinic, please enter the contact information below:
Agency/Clinic Name County
Street Address
City, State Zip ,
Phone
 * Phone numbers must be entered in the (xxx) xxx-xxxx format 		Fax
 * Phone numbers must be entered in the (xxx) xxx-xxxx format

Primary Concerns
What services are you seeking from the CDL for your child? Please be specific as possible
1
2
What are your 3 primary concerns about your child? Please be as specific as possible.
1
2
3

Diagnoses/Assessments
Has your child been assessed previously for school performance, learning, behavioral, developmental and/or social-emotional problems?
If yes, where and when?
Diagnosis and/or IQ?
Does your child receive special education, therapies, and/or behavioral-emotional support services either in or outside of school?
If yes, please describe.
Has this individual been seen at UNC Hospitals or any UNC Clinics before?
If yes, please provide his or her UNCH medical record #:
Do we have permission to contact you about your child participating in a research study?
(Please call Ugonna Ukwu at 966-4788 if you have any questions about our research study).

Clinical Evaluations
At this time our Center offers clinical evaluations that target children whose previous assessments and services have not yet fully enhanced their learning and development. Depending on the child's needs, evaluation services may be provided by individual clinicians, small teams of 2 or 3 clinicians, or a full interdisciplinary team. Our clinical staff will review this form to determine the disciplines to include in your child's evaluation. At the present time we have a lengthy waiting list for evaluations.