Early Intervention Referral

( * ) indicates required field

Referral Source Name

Referral Source Phone Number

Referral Source Address (street, city, state, zip code)

Referral Source Agency/Relationship to child

Is the parent aware you are making this referral

Yes

Child first and last name

Child date of birth (MM/DD/YYYY)

Child address (street, city, state, zip code)

Child gender

Child race (American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, Other) (please include all that apply)

Child ethnicity (Hispanic or Not Hispanic)

Hispanic

Not Hispanic

Child language

Parent/Guardian name

Parent/Guardian phone number

Parent/Guardian address (street, city, state, zip code)

Parent/Guardian dominant language

If not English, is an interpreter needed

Yes

Foster parent name

Foster parent phone number

Foster parent address

Oneida County case worker name

Oneida County case worker phone number

Additional notes for foster care if needed

-Confirm diagnosis or Suspected Delay/Concern: Early Intervention Evaluation (This child has a confirmed disability or suspected of having a disability, developmental delay, or diagnosed condition likely to result in developmental delay.)

-At Risk of Delay: Early Intervention Child Find Monitoring (This child is NOT suspected of having a disability at the present time but is being referred because he or she is at risk of developing a disability in the future.)

Please describe your concerns or share addition details

Additional Details

Oneida County Partners

Early Intervention Referral

Oneida County Special Children Services Early Intervention Referral Form