Get Alabama Early Intervention Referral Form

Completing the Alabama Early Intervention Referral Form online is a straightforward process that helps ensure infants and toddlers receive the early intervention services they need. This guide provides clear instructions to assist you in navigating each section of the form effectively.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by providing infant or toddler information. Fill in the child’s Social Security number if available, date of birth, last name, and first name. Indicate if your child is of Hispanic or Latino origin by checking 'Y' for yes or 'N' for no. Next, mark the child’s primary race by checking the appropriate box.
3. Continue with additional details such as home language, sex, and insurance information. Be sure to clearly indicate if your child has Medicaid or private insurance by checking 'Y' for yes or 'N' for no.
4. Proceed to the child relation information. Provide the first name, last name, and middle initial of the person related to the child. Indicate the relationship type and confirm if this is the primary relation by checking 'Y' or 'N'.
5. Fill in the mailing address, city, state, and zip code. If the physical address is different, provide that information as well. Include the primary contact’s phone number, alternate contact number, and work phone number as needed.
6. In the referral source information section, specify the individual making the referral and the referral source, along with the county and contact phone number. Clearly state the reason for referral and how the family learned about Child Find.
7. If applicable, the physician or CRNP section needs to be completed by a medical professional. They will certify the child’s diagnosis, provide their printed name and phone number, sign, and date the form.
8. After completing all sections, review the form to ensure all information is accurate and clear. Save your changes, and make sure to download, print, or share the completed form as necessary.

Complete your Alabama Early Intervention Referral Form online today to ensure timely support for your child.