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Ide ACS Referral Hotline: (877)-885-KIDZ(5439) to make a referral to the Early Intervention Program CHILD S NAME: (Last, First, Middle) DATE OF BIRTH: CHILD S ADDRESS: (Street, Apt. No) Male Female RACE (may select more than one if applicable): White Asian Black Native American or Alaskan Hawaiian or Pacific Islander CITY: (MM/DD/YY) / / SEX MOTHER S NAME: (Last, First, Middle) ETHNICITY: Hispanic TELEPHONE: Not Hispanic Home ( ) - Careg.

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Families, doctors, and community members can make a referral by: Calling 311 and asking for Early Intervention. Completing the Early Intervention Program Referral Form (Fillable PDF) and faxing it to a regional office in the family's home borough.

To be eligible for services, children must be under 3 years of age and have a confirmed disability or established developmental delay, as defined by the State, in one or more of the following areas of development: physical, cognitive, communication, social-emotional, and/or adaptive.

In New York City, children with developmental delays and disabilities under three may receive these supports through Early Intervention (EI), run by the Department of Health and Mental Hygiene (DOHMH).

Health care providers should make referrals by calling 311 and asking for Early Intervention, or by filling out the Early Intervention Program Referral Form (PDF) and faxing it to the regional office in the child's borough of residence.

How to Apply for Approval as an Early Intervention Agency: To obtain approval, the applicant must submit a completed Agency Application/Provider Agreement, including all required schedules and attachments, to the New York State Department of Health (Department).

EIP is available to all families in New York City regardless of income or immigration status. There is no cost to families. Your health insurance, including Medicaid, may be used to pay for Early Intervention services, at no direct cost to you or impact on health benefits.

What is transition? Transition includes steps that help a child who is receiving early intervention services move on to the preschool special education program. Some children may continue on with other programs or services. Or it may be decided that a child may no longer need services.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232