Early Intervention Referral Form - Capital Area Intermediate Unit 15

Child's Namerequired

First Name

Middle (optional)

Last Name

Child's Addressrequired

Street, City, State, Zip, County

School District Where Child Lives:required

What language is the child exposed?required

Parent 1 Information:

Parent's Namerequired

First Name

Last Name

Email Addressrequired

Lives with Child?

If No, list address

Parent 2 Information:

Parent's Name

Last Name, First Name, Middle Initial

Email Address

Lives with Child?

If No, list address

Street, City, State, Zip

What languages are spoken in the home:required

Please list other languages your child is exposed to:

Dialect

Interpreter needed for parents?requiredAn interpreter will be provided in your child's native language.

Yes

No

An interpreter will be provided in your child's native language.

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

Legal Guardian/Foster Parent's name(s)

Last Name, First Name, Middle Initial

Please provide a copy of your legal documents

Attach up to 1 file with a maximum size of 20MB

No file chosen

Relationship

Guardian/Foster Parent's home phone

Guardian/Foster Parent's cell phone

Guardian/Foster Parent's work phone

Guardian/Foster Parent's Email

Who has education rights?

Whoever has education rights. Please sign and attach early Intervention documents:

Attach up to 1 file with a maximum size of 20MB

No file chosen

PRESCHOOL/DAYCARE INFORMATION

Where:required

Provide Name & Address

What days of the week?required

Times:required

MEDICAL and PSYCHOSOCIAL HISTORY

Describe any significant medical problems, past or current:

(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

By whom was the disorder diagnosed by? Please explain hearing and vision concerns.required

Please describe any allergies.required

Have glasses been prescribed?

Yes

No

Have hearing aides been provided?

Yes

No

Please describe any other type of diagnosis not listed.

Attach Any Reports (Related to diagnosis)

Attach up to 1 file with a maximum size of 20MB

No file chosen

If your child received an evaluation and IEP from another IU or state, please upload documents here:

Attach up to 1 file with a maximum size of 20MB

No file chosen

Please describe your concernsrequired

Form Completed by: required

Relationship to child:required

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.

I will be completing the online screener.

ASQ screener is required in order for referral to be processed.