Illinois Early Intervention Program Referral Fax Back Form - Department Of Healthcare And Family Services


State of Illinois
Department of Healthcare and Family Services
Illinois Early Intervention Program Referral Fax Back Form
PART 1 of 2
Complete Part I upon contacting the family, or when a family cannot be contacted in a timely matter. If the parent/guardian
consented to the release of information in Section 6 of the Standardized Illinois Early Intervention Referral Form to the
primary care provider listed in Section 4 and/or the referral source listed in Section 3, send Part 1 of the Referral Fax Back
Form to the primary care provider and/or the referral source for which consent was provided. If the parent/guardian did not
consent to the release of information to either the primary care provider (PCP) or the referral source, then information cannot
be sent to the entity for which consent was not given.
Date: _____/_____/_____
Child’s Name: ___________________________________________
DOB: _____/_____/_____
Parent/Guardian Name: __________________________________________
Date Referral Received: _____/_____/_____
This child was referred to our Child and Family Connections (CFC) office. The following is the status of that referral:
The family was contacted on (date): _____/_____/_____
A Service Coordinator has been assigned to the family:
Name: __________________________________________
CFC # / Location: _____ / __________________________________________
Phone Number: _____ - _____ - __________
Fax Number: _____ - _____ - __________
E-Mail: __________________________________________
Repeated attempts have been made to contact this family - we were unable to establish contact.
Date final contact attempt made: _____/_____/_____
Please let us know if the family is still interested in having an evaluation for their child.
The family has been contacted and requests that you contact them directly for results.
Date request made by family: _____/_____/_____
The family has declined services at this time.
Date service declined: _____/_____/_____
Additional comments:
Version date August 2013
HFS 652 (N-7-14)


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