Standardized Illinois Early Intervention Referral Form

ADVERTISEMENT

Standardized Illinois Early Intervention Referral Form
Please complete Sections 1 through 6 of this form to refer a child to Early Intervention (EI) for eligibility determination.
Section 1. Child Contact Information
Child Name: _______________________________________
If the child is known by another name enter it here: _____________________________________________________
Date of Birth: _____/_____/_____ Child Age: _____ Gender: M F
Race: ______________________
Street Address: _________________________________________________________________________________
City: _____________________________State: ________________ Zip: ____________ County: _________________
Type of Insurance Coverage:
Medicaid
Private Insurance
Parent/Guardian Name: _________________________________ Relationship to Child: ________________________
Primary Language: _______________ Home Phone: _____/_____-_______ Other Phone: _____/_____-_______
Alternate or Emergency Contact Person: ___________________________Phone: _____/_____-_______
Section 2. Reason(s) for Referral
Reason(s) for referral to EI (Please check all that apply):
 Identified condition or medical diagnosis (e.g., Spina Bifida, Down Syndrome): ___________________________
 Suspected developmental delay based on objective developmental screening using (please note screening tool used)
_________________________________ (Please check area[s] of concern):
___Motor/Physical ___Cognitive ___Social/Emotional ___Speech ___Language/Communication
___Behavior ___Vision/Hearing ___Adaptive/Self-help Skills ____Other, specify___________________
Comments: ____________________________________________________________________________________
 Environmental Factors (“at risk”) (Please describe environmental risk factors):_____________________________
 Other (Please describe): _______________________________________________________________________
 Family is aware of reason for referral
Section 3. Referral Source Contact Information
If the Primary Care Provider is the source of referral, skip Section 3, go to Section 4 and check here
Referral Date: _____/_____/_____
Name of Agency Making Referral: __________________________________________________________
Address: ______________________________________________________________________________________
City: ___________________________ State: __________
Zip Code: _______________
Office Phone: _____/_____-_______ Office Fax: _____/_____-_______ E-mail: _______________________________
Contact Person at Referral Site: _____________________________________________________________________
Version Date August 2013
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2