Referal/Screening Information

This form should be used by any community member (i.e. doctors, parents, etc.) to make a referral to the Early Intervention/Early Childhood Special Education program if there is concern regarding development for children ages birth to 5 years of age. If you are not the parent making the referral please make sure the parent is aware that you are referring their child.

Other formats: Printable PDF

Date: *

Person making referral: *

Agency Name or Relationship to the Child: *

If you are submitting this referral through an agency, please list the agency name here. Otherwise, please state your relationship to the child.

Child's Full Name: *

Nickname:

Date of birth: *

Sex: *

Father's Full Name: *

Mother's Full Name: *

Foster Parents' Full Names:

Child lives with: *

If other, please enter here:

Physical Address: *

(Street, City, Zip)

Mailing Address (if different):

Home Phone: *

(Include area code)

Work Phone (Father):

Work Phone (Mother):

Cell Phone (Father):

Cell Phone (Mother):

Email Address:

Message Phone:

(Enter the message phone, complete with area code, and list whose phone number it is.)

Does child have health insurance?: *

Yes

Ethnicity: *

Primary Language of Child: *

Primary Language of Parents: *

Interpreter Needed?: *

Yes

Attends Preschool: *

Yes

Name of Preschool:

Teacher Name:

Time:

Has child ever received EI or ECSE services?: *

If so, where and when?:

Specific Concerns:

Diagnosed medical conditions:

Child's Doctor:

Clinic:

Clinic Address:

Clinic Phone:

Clinic Fax:

InterMountain Education Service District

EI/ECSE

Referal/Screening Information