Early Intervention/early Childhood Special Education (Ei/ecse) Referral Form For Providers* Birth To Age 5 Form (Page 2 of 4) in pdf

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

EDICAL

ONDITION

TATEMENT FOR

ARLY

NTERVENTION

LIGIBILITY

(

BIRTH TO AGE

Date: __________

Child’s Name: _________________________________________

Birthdate: _________

The State of Oregon, through the Oregon Department of Education, provides services to young children with significant

developmental problems. The Department recognizes that disabilities may not be evident as delays in infants and very young

children, but, without intervention, the child will become developmentally delayed.

The above named child may have such a condition. Oregon law requires that a physician, physician assistant, or nurse

practitioner with the appropriate State Board licensure, examine the child and determine whether the child has a physical or

mental condition that is likely to result in a developmental delay.

The Oregon Department of Education requests your assistance in determining this child’s eligibility for Early Intervention (EI)

services. While many children may benefit from EI services, please understand that this program has been established to serve

only those infants and young children in whom developmental delays are evident or likely to develop.

Medical Condition:

____________________________________________________________________________________________________

Please indicate if this child has a:

Vision Impairment

Hearing Impairment

Orthopedic Impairment

Comments:

____________________________________________________________________________________________________

Yes

This child has a physical or mental condition that is likely to result in a

developmental delay.

________________________________________________________________

_________________________

Physician/Physician Assistant/Nurse Practitioner

Date

Oregon law requires that a physician, physician assistant, or nurse practitioner, with the appropriate State Board licensure determine whether the child has a physical or mental

condition that is likely to result in a developmental delay. For a physician and physician assistant this licensure in Oregon is from the State Board of Medical Examiners. For a nurse

practitioner in Oregon this licensure is from the State Board of Nursing. Physicians, physician assistants, and nurse practitioners from other states must have the appropriate

requisite licensure for their State. This form is used by the physician, physician assistant, or nurse practitioner to indicate the child’s diagnosis for special education purposes.

Print Name: ________________________________________ Phone: ______

Please return to: _____________________________________________________________________________________

_____________________________________________________________________________________

Submit this with EI/ECSE Referral Form to the EI/ECSE program in the child’s county of residence.

Copies of this form

may be obtained from the Oregon Department of Education,

(Form 581-5150D-X (4/12))

Early Intervention/Early Childhood Special Education

or on-line at

Form Rev. 06/20/2012