Referral for Evaluation for Early Intervention

An evaluation is needed to determine a child's eligibility for Early Intervention services. There is no cost for an evaluation. Please complete the form below. Required fields marked with an asterisk *

Child's Name*

Answer Required

Parent's Name*

Answer Required

Parent's E-Mail Address

Answer Required

Child's Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone Number*

Answer Required

Child's Date of Birth (mm/dd/yyyy)*

Answer Required

Last 4 Digits of Child's Social Security Number*

Answer Required

School District of Residence*

Answer Required

Child's Race*

Answer Required

Black or African-American

American Indian or Alaskan Native

Asian

White

Native Hawaiian or Pacific Islander

Other:

Name the Current Child Care Center or Preschool Program

Answer Required

Please select the area(s) of development that you are concerned with. Choose all that apply.*

Answer Required

Cognitive Development

Communication Development

Social/Emotional Development

Physical Development

Adaptive Development

Briefly describe your concerns*

Answer Required

Who referred you to Early Intervention/How did you find out about Early Intervention?*

Answer Required

Please fix the highlighted areas below before submitting.

Referral for Evaluation for Early Intervention