Universal Referral Form
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4Universal Referral Form
for Early Intervention/Early Childhood Special Education (EI/ECSE) Providers
*
CHILD/PARENT CONTACT INFORMATION
Child’s Name: __________________________________________________________ Date of Birth: ______/______/______
Parent/Guardian Name: ___________________________________________ Relationship to the Child: ________________
Address: ___________________________________________City: ________________________ State: ______ Zip: ______
County: ________________ Primary Phone: _____________ Secondary Phone: _____________ E-mail: _______________
Primary Language: ______________________________________ Interpreter Needed:
Yes
No
Type of Insurance:
Private
OHP/Medicaid
TRICARE/Other Military Ins.
Other (Specify)___________________
No insurance
Child’s Doctor’s Name, Location And Phone (if known): _______________________________________________________
PARENT CONSENT FOR RELEASE OF INFORMATION
(more about this consent on page 4)
Consent for release of medical and educational information
I, _________________________________ (print name of parent or guardian), give permission for my child’s health provider
_________________________________ (print provider’s name), to share any and all pertinent information regarding my
child, ____________________________ (print child’s name), with Early Intervention/Early Childhood Special Education
(EI/ECSE) services. I also give permission for EI/ECSE to share developmental and educational information regarding my child
with the child health provider who referred my child to ensure they are informed of the results of the evaluation.
Parent/Guardian Signature: _________________________________________________ Date: ______/______/______
Your consent is effective for a period of one year from the date of your signature on this release.
OFFICE USE ONLY BELOW:
Please fax or scan and send this Referral Form (front and back, if needed) to the EI/ECSE Services in the child’s county of residence
REASON FOR REFERRAL TO EI/ECSE SERVICES
Provider: Complete all that applies. Please attach completed screening tool.
Concerning screen:
ASQ
ASQ:SE
PEDS
PEDS:DM
M-CHAT
Other:_______________________
Concerns for possible delays in the following areas (please check all areas of concern and provide scores, where applicable):
Speech/Language _______
Gross Motor_______
Fine Motor _______
Adaptive/Self-Help _______
Hearing _______
Vision _______
Cognitive/Problem-Solving _______
Social-Emotional or Behavior_______
Other: _____________________
Clinician concerns but not screened: ______________________________________________________________________________
Family is aware of reason for referral.
Provider Signature: __________________________________________________ Date: ______/______/______
If a child under 3 has a physical or mental condition that is likely to result in a developmental delay, a qualified Physician, Physician Assistant, or Nurse
Practitioner may refer the child by completing and signing the Medical Statement for Early Intervention Eligibility (reverse) in addition to this form.
PROVIDER INFORMATION AND REQUEST FOR REFERRAL RESULTS
Name and title of provider making referral: __________________________________ Office Phone: _____________ Office Fax: _________________
Address: _____________________________________________________City: ________________________________ State: ______ Zip: _______
Are you the child’s Primary Care Physician (PCP)? Y___ N___
If not, please enter name of PCP if known: ____________________________________
I request the following information to include in the child’s health records:
Evaluation Report
Eligibility Statement
Individual Family Service Plan (IFSP)
Early Intervention/Early Childhood Special Education Brochure
Evaluation Results
EI/ECSE EVALUATION RESULTS TO REFERRING PROVIDER
EI/ESCE Services: please complete this portion, attach requested information, and return to the referral source above.
Family contacted on ______/______/______ The child was evaluated on ______/______/_____ and was found to be:
Eligible for services
Not eligible for services at this time, referred to: _____________________________________________________________
EI/ECSE County Contact/Phone: _______________________________ Notes:__________________________________________________________
Attachments as requested above: :______________________________________________________________________________________________
Unable to contact parent
Unable to complete evaluation EI/ECSE will close referral on ______/______/______.
* The EI/ECSE Referral Form may be duplicated and downloaded from the ABCD Child Health Provider Toolkit website:
Form Rev. 09/25/2012
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