Form Dcd-0093 - Referral For Child Care Children With Special Needs
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1
2REFERRAL FOR CHILD CARE
CHILDREN WITH SPECIAL NEEDS
Date:_______________
To:_______________________________________Agency:_____________________________________
From:____________________________________Agency:______________________________________
I. Family Information
Child’s Name:__________________________________________________Date of Birth:_____________
Parent’s Name:__________________________________________Telephone:(
) _________________
Address:_______________________________________________________________________________
______________________________________________________________________________________
City
State
Zip Code
II.
Program Eligibility
Birth to age three deemed eligible for the N.C. Infant-Toddler Program based on criteria from the
Children’s Developmental Services Agency (CDSA) or other referring agencies:
Briefly describe the special needs of the child:_________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Individualized Family Services Plan (IFSP) has been signed by:
________________________________________________________________
____________________
Representative of CDSA
Date
Ages three through five deemed eligible for the Preschool Program by the local school system or age
five through seventeen and eligible for the Exceptional Children’s Program.
Briefly describe the special needs of the child
:___________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Individualized Educational Plan (IEP) has been signed by:
________________________________________________________________ ____________________
Representative of LEA
Date
Ages birth through five deemed eligible for community-based at risk preschool services by the local
public health department.
Briefly describe the special needs of the child:_________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Personal Care Plan (PCP) has been signed by:
__________________________________________________________________________________ ____________________
Representative of PHD
Date
NOTE: Children with special needs ages birth to five whose parents have declined participation in the NC
Infant-Toddler Program or the Department of Public Instruction’s Preschool Program are eligible to receive
targeted case management services in the local public health department’s Child Service Coordination
Program.
Referral For Children With Special Needs
A copy of the
outlining the service delivery plan is needed for
each child if supplemental funds are anticipated.
White Original and Yellow Copy: Local DSS or LPA
DCD-0093
Rev. 9/07
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