Form Icrc 591 - Early Start Program - California Welfare & Institutions

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EARLY START PROGRAM
CONFIDENTIAL CONSUMER INFORMATION
Referral Form
Inland Counties Regional Center
See California Welfare & Institutions
Code, Section 4514
Today=s Date:__________________
CHILD=S NAME:________________________________________
DOB:___________________
AKA:__________________________________________________
Sex: ___________________
Referral #:_______________
Referral Date:____________________ Previous Contacts
Yes
No Parents Informed of Referral:
Yes
No
Referred By:_____________________________________________________________________________________________
Referral Source: ____Mom/Dad
_____Department of Child & Family Services (DCFS)
_____County Health Department
_____Physician
_____Child Protective Services (CPS)
_____Local Education Area (LEA)
_____Foster Family Agency
_____Hospital Discharge Planning Team
_____Calif. Child Serv. (CCS)
_____Priv. Service Agency
_____Early Start Service Coordinator
_____Family Resource Network (FRN)
_____Other_____________________________________________________________
Parents/Guardian/Foster*__________________________________________________ Home District:______________________
Address:_________________________________________________________________________________________________
(List both street & mailing address if different)
Home Phone: ________________________ Cell Phone:_________________________Work Phone________________________
*DCFS SW: Name_________________________________Address:_________________________________________________
Medi-Cal:
Yes
No
Phone #_____________________________
Living With: _______Parent _______ Foster _______Licensed Children=s Institution Educational Rights: _____Yes
_____No
Child Language: _____Eng _____ Span Home Language: _____Eng _____Span
Ethnicity: _____Caus ____ Hisp _____Blk
Other:__________________________
Other:____________ ______________
Other:____________________________
Reasons for Referral:
Speech/Language
R/O Autism
Developmental Delay
Neurological
Prematurity
Cerebral Palsy
Seizures
Medical
Hearing
Vision
Ortho
Other Reasons:____________________________________________________________________________________________
Primary Physician: ________________________________________________ Phone:___________________________________
Specialists:______________________________________________________ Phone:___________________________________
Diagnosis:________________________________________________________________________________________________
Other Agency Involvement:
CCS
WIC
Another R.C. UCI #:_____________________________
Previous Program:
Yes
No
Previous IFSP:
Yes
No
Name:___________________________________________________________________________________________________
Referral
Denial
SENT TO:
Parent
School
IRC
CCS
DPSS
Private Programs
Mental Health
Public Health
Completed By:_____________________________________________ Agency:________________________________________
Phone Number:________________________ Date Sent:________________ Attn. To:___________________________________
Caseworker/Teacher:____________________________________________ Case #: ____________________________________
Date Opened/Assessed: _____/_____/_____
IRC Caseload:_________________________
ICRC 591 (6/05)

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