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 *

Parent's Name *

Parent's E-mail Address

Child's Address

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Phone Number *

Child's Date of Birth

Last 4 Digits of Child's Social Security Number *0 / 4

School District of Residence *Please select an optionAliquippa School DistrictAmbridge Area School DistrictBeaver Area School DistrictBig Beaver Falls Area School DistrictBlackhawk School DistrictCentral Valley School DistrictFreedom Area School DistrictHopewell Area School DistrictMidland Boro School DistrictNew Brighton Area School DistrictRiverside Beaver County School DistrictRochester Area School DistrictSouth Side Area School DistrictWestern Beaver County School District

Child's Race *American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Pacific IslanderWhiteOther

If race is other

Child's Ethnicity *Please select an optionHispanicNon-Hispanic

Child's Gender *Please select an optionMaleFemale

Is the Child a Citizen of the United States of America? *Please select an optionYesNo

Name the Current Child Care Center or Preschool Program

Has the Child Ever Received Early Intervention Services?YesNo

Please select the area(s) of development that you are concerned with. Choose all that apply *Cognitive DevelopmentCommunications DevelopmentSocial/Emotional DevelopmentPhysical DevelopmentAdaptive Development

Briefly describe your concerns *

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

What is your relationship to the child?Parent/GuardianOther Family MemberTeacherCaregiverAgencyOther

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