Get Early Start Program Referral Form

Navigating the Early Start Program Referral Form can be challenging. This guide aims to provide clear and supportive instructions for users filling out the form online, ensuring that all necessary information is accurately captured.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the date at the top of the form. Ensure to enter the child's date of birth and sex in the designated fields.
3. Complete the referral number to track your submission.
4. Enter the child's name and any known aliases. Make sure the names are spelled correctly to avoid any identification issues.
5. Indicate the date of referral and previous contacts made, if any, ensuring to inform if the parents were notified.
6. Identify yourself in the 'Referred By' section by checking the appropriate source from the available options and providing the required contact information.
7. Input the parents', guardian's, or foster guardian's information, including their complete address and multiple phone numbers for contact purposes.
8. Specify the living situation of the child and educational rights status, as well as the child's primary and home languages.
9. Select the child's ethnicity and provide any additional relevant information pertaining to ethnicity or other details.
10. Detail the reasons for the referral by checking all applicable boxes, along with specifying any other reasons that may not be listed.
11. Fill in the primary physician's name and contact information, as well as any specialists involved in the child's care.
12. Describe any other agency involvement or previous programs the child has participated in.
13. Ensure that all assessments and their details are completed accurately to reflect the child’s development.
14. Upon completing the form, review all entries for accuracy before submitting.
15. You can save changes, download, print, or share the form as needed after finalizing the information.

Complete the Early Start Program Referral Form online today to ensure timely support for children in need.