Early Intervention Intake & Assessment

Check Your Child's Milestone

Fill in this form to begin your child's journey with DCCD. A specialist will reach out within 24 hours to schedule your assessment.

No documents needed

Step 1 of 6Personal Information

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Personal Information

1. Name of Your Child *

2. Date of Birth *

3. Gender *

4. Father's Name

5. Father's Mobile Number *

6. Father's Email Address

7. Mother's Name

8. Mother's Mobile Number

9. Mother's Email Address

10. Any Parental Concerns *

11. Concerns at School (if any)

12. Since When Did You Notice These Concerns?

13. Languages Your Child is Exposed To

14. History of Recent Re-location, if any

15. Pin/Zip Code *

16. Referred By *

Your information is kept strictly confidential and used only to schedule your assessment.