Kansas Infant-Toddler Services (Tiny-K) Early Intervention Program Referral Form
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1Kansas Infant-Toddler Services (tiny-k) Early Intervention Program Referral Form
Please complete this form to refer a child to Early Intervention (tiny-k/Part C). Please indicate the feedback that you would like to receive
from the Early Intervention Program in response to your referral. Primary referral sources must make a referral as soon as possible, but not
more than seven days after the child has been identified as needing further evaluation.
Parent/Child Contact Information
Child First Name: _____________________________ Middle Initial:______ Last Name: _________________________________
Date of Birth: ______/_______/_______
Child Age (Months): _______
Gender: M F
Home Address: _____________________________________________________ City: _________________ State: _____ Zip: __________
Parent/Guardian________________________________ Relationship to Child: ____________________ E-mail: _______________________
Primary Language Spoken in the Home: ___________________ Home Phone:____________________ Other Phone:__________________
Reason(s) for Referral to E arly Intervention
(Please check all that apply)
Identified condition or diagnosis (e.g., spina bifida, Down syndrome): ______________________________________________________
Suspected developmental delay or concern (Please circle areas of concern):
Motor/Physical
Cognitive
Social/Emotional
Speech/Language
Behavior
Other_______________________________________
At Risk (Describe risk factors): _____________________________________________________________________________________
Other (Describe): _______________________________________________________________________________________________
Referral Source Contact Information
Person Making Referral: _______________________________________________________ Date of Referral: _______/________/_______
Address: ________________________________________________________________________________________________________
Office Phone_______________________Office Fax: _________________________ E-mail______________________________________
Local tiny-k Program Information
Program Name: _________________________________________________________________________________________________
Address: __________________________________________________City: ________________________ State: ____ Zip: ___________
Office Phone_______________________Office Fax: _________________________ Email:
______________________________________________
Feedback Requested by the Referral Source
Date Referral Received: ______/_______/_______
Date of Initial Appointment with Child/Family: ______/_______/_______
Name of Assigned Service Coordinator: ________________________________________________________________________________
Office Phone: _____________________ Office Fax: ____________________________ E-mail: ___________________________________
After initial appointment, please send the following information:
□
Changes in Services Being Provided
Status of Initial Family Contact
□
Periodic Progress Reports/Summaries
Developmental Evaluation Results
□
Individual Family Service Plan (IFSP), if developed
Services Being Provided to Child/Family
□
Other (describe): __________________________
(Including: names of providers and frequency of services)
Release of Information Consent
Note to providers: Parental consent is not necessary in order for a referral to be made.
I,________________________________________ (print name of parent or guardian), give my permission for the early intervention
program to share developmental and educational information regarding my child,_____________________________________________
(print child’s name), with the provider who referred my child to ensure the provider is informed of the results of the evaluation.
Parent/Legal Guardian Signature__________________________________________________________ Date:________/________/________
Your consent is effective for a period of one year from the date of your signature on this release.
Please fax the completed form to your local tiny-K program.
Visit to locate contact information for the tiny-K program that serves your county.
Adapted from Early Intervention Program Referral Form developed by the American Academy of Pediatrics (AAP)
12/2015
and the Tracking, Referral, and Assesment Center for Excellence (TRACE)
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