Get Strongstart Referral Form English - Dc Aap - Aapdc

Filling out the StrongStart Referral Form is a crucial step in accessing early intervention services for children. This guide will provide you with detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the StrongStart Referral Form.

1. Click 'Get Form' button to obtain the StrongStart Referral Form and open it for editing.
2. Enter child identification information. Fill in the child's legal name, date of birth, and gender. Indicate ethnicity/race and enter the insurance name and number.
3. Provide the parent(s) or legal guardian's contact details, including their name, telephone number, and address. Specify the ward and the primary language spoken by the parent(s)/guardian.
4. If applicable, include information for foster parent(s) such as their names, contact details, and address. Indicate how long the child has resided at the current residence.
5. Confirm if a surrogate, advocate, or guardian ad litem is involved. If yes, provide the name and contact details.
6. Enter referral information. Write the name of the referring person and their agency or practice. Include the referring person's phone and fax numbers.
7. Indicate if the referring person is a qualified health professional. If yes, check the appropriate box and specify the discipline.
8. Check if a developmental screening has been completed. If yes, note the tools used and attach the relevant documentation. Otherwise, check the 'No' option.
9. Complete one of the required statements regarding the child’s screening or diagnosis and describe any concerns regarding development.
10. Sign and date the form as the referring person.
11. In the consent to release information section, the parent or legal guardian must authorize the release of specific information and initial all boxes to indicate understanding before signing and dating.
12. Finally, save any changes, download, print, or share the completed form as needed.

Complete your StrongStart Referral Form online today for timely processing.