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How to fill out the Early Intervention Referral Form online
The Early Intervention Referral Form is a critical document for referring a child to Early Intervention services for eligibility determination. This guide provides step-by-step instructions on how to complete the form online effectively and accurately.
Follow the steps to fill out the Early Intervention Referral Form:
- Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
- In Section 1, input the child's contact information, including their full name, date of birth, and age. Specify any known alternate names, along with the child's gender, race, address, insurance details, and the contact information for the parent or guardian. Ensure that all fields are filled out carefully for accurate processing.
- In Section 2, indicate the reasons for referral by checking all applicable boxes. Provide details regarding any identified medical conditions or suspected developmental delays, including the specific areas of concern. Add any additional comments that may help clarify the referral.
- If applicable, complete Section 3 by providing the referral source contact information. If the Primary Care Provider made the referral, select the designated box to skip this section.
- In Section 4, enter the Primary Care Provider's contact information, including their name, address, phone number, and email. This information is crucial for coordinating services.
- Fill in Section 5 with the CFC number corresponding to the child's referral location. Use the provided resources to locate the correct CFC office as needed.
- Complete Section 6 by signing the Authorization to Release Information. Ensure that all required names and details are filled in correctly. Be aware that consent is valid for a period of 12 months.
- Review the completed form for accuracy. Once satisfied, users can save changes, download, print, or share the form as appropriate.
Encourage others to complete their Early Intervention Referral Form online today for efficient processing.
What is ECI? Early Childhood Intervention (ECI) is a statewide program within the Texas Health and Human Services Commission for families with children birth up to age 3, with developmental delays, disabilities or certain medical diagnoses that may impact development.
Fill Early Intervention Referral Form
Referral forms without a signed consent form will not be accepted. Please complete Sections 1 through 6 of this form to refer a child to Early Intervention (EI) for eligibility determination. Please complete this form for referring a child to Early Intervention (Part C) if you prefer to do so in writing. Early Childhood Early Intervention. Public Children's Service Agency (PCSA) Referral Form. This form is required for any referral from a PCSA in Ohio for children under age three. If you have questions, please call us at 585-753-KIDS ). Anyone who has a concern about a child's development can make a referral. This includes parents, guardians, foster parents and family members. Please complete this form to refer a child to Early Intervention Services.
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