Eligibility

Early Childhood Birth-to-3 Referral Form

Parent / Guardian Name

Phone

Address

City, State, Zip

Email

Child's Name

Date of Birth

Diagnosis

Children from birth through age 2 with a diagnosed disability, a condition with a high probability of resulting in a delay, or who demonstrate a delay in at least one area of development listed above may be eligible for Early Intervention services. Please mark the area of suspected delay.

Large Muscle Movement (rolling, crawling, walking)
Small Muscle Movement (holding a bottle, rattle, toys)
Speech and Language Skills (feeding, understanding others, saying words)
Cognitive Skills (thinking and learning, how your child plays with/interacts with toys and environment)