Screening Form - Florida Department Of Health Page 3

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4. Does your child need or get special therapy, such as physical, occupational, or speech therapy?
________ Yes – Go to Question 4a
________ No – Go to Question 5
4a. Is this because of ANY medical, behavioral, or other health condition?
________ Yes – Go to Question 4b
________ No – Go to Question 5
4b. Is this a condition that has lasted or is expected to last for at least 12 months?
________ Yes
________ No
4c. What is the condition or diagnosis? ______________________________________________
5. Does your child have any kind of emotional, developmental, or behavioral problem for which he or she
needs to get treatment or counseling?
________ Yes – Go to Question 5a
________ No
5a. Has this problem lasted or is it expected to last for at least 12 months?
________ Yes
________ No
5b. What is the condition or diagnosis? ______________________________________________
 
Child is eligible if all parts of question 3 and all parts of any other question is yes
Child needs Level II Screening if all parts of question 3 only were answered yes, if the child answered 
yes to three of the five questions as yes, however, does not meet criteria outlined in the above 
 
bullet, or if the child has four or more diagnoses.
CMS ELIGIBLE?     
YES  
         NO  
 
Needs Level II  
 
Completed by: _______________________________   
Date: __________________ 
Form DH8000 (12/2015)
Rule 64C-2.002, Florida Administrative Code
3
 
 

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