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Early Intervention Referral Form

Required

Child's Namerequired
First Name
Middle (optional)
Last Name
Must contain a date in M/D/YYYY format
Street, City, State, Zip, County
What is the Child's Race?required

Parent 1 Information:

Parent's Namerequired
First Name
Last Name
xxx-xxx-xxxx

Parent 2 Information:

Last Name, First Name, Middle Initial
xxx-xxx-xxxx
Street, City, State, Zip
Interpreter needed for parents?requiredAn interpreter will be provided in your child's native language.
An interpreter will be provided in your child's native language.

To be completed only if this child has a legal guardian/foster parents

Last Name, First Name, Middle Initial
Attach up to 1 file with a maximum size of 20MB
No file chosen
Attach up to 1 file with a maximum size of 20MB
No file chosen

PRESCHOOL/DAYCARE INFORMATION

Does your child attend any of the following?required
Provide Name & Address

MEDICAL and PSYCHOSOCIAL HISTORY

(Surgeries, hospitalizations, illness, etc.)
If your child has been given a diagnosis, please check and provide a copy of any reports (related to that diagnosis) that you may have in your possessionrequired
Have glasses been prescribed?
Have hearing aides been provided?
Attach up to 1 file with a maximum size of 20MB
No file chosen
Name
Please check box below to confirm that you will complete the online screener after submitting this referral. The link will pop-up upon completion of this form.requiredASQ screener is required in order for referral to be processed.
ASQ screener is required in order for referral to be processed.