EI Referral Form – County of Saratoga, New York

Referral Source Information

Date

Name

Agency or Facility (if any)

Address (Street, Apt #)

City

State

Zip Code

Phone Number

Fax Number

Referral Source

Other Referral Source

Reason for Referral

EARLY INTERVENTION: Child with a suspected or known developmental delay or disability

AT RISK/CHILD FIND: Child who is developing typically but may be “at risk” for atypical development or failed a Newborn Hearing Screening or SSL Section 422 (13) Child Under 3, Parent Subject of Ind. Report

Specify diagnosis or developmental concern(s)

Child's Name

Child's Date of Birth

Sex

Male Female

Child's Address (Street, Apt #)

City

Zip Code

Race

White Asian Black Native American or Alaskan Hawaiian or Pacific Islander Prefer not to answer

Ethnicity

Hispanic Non-Hispanic Prefer not to answer

Parent/Guardian #1 Name

Parent/Guardian #1 Relation to Child

Mother Father Grandparent Foster Parent Other

Other, please specify

Parent/Guardian #1 Home

Parent/Guardian #1 Cell

Parent/Guardian #1 Email Address

Parent/Guardian #2 Name

Parent/Guardian #2 Relation to Child

Mother Father Grandparent Foster Parent Other

Other, please specify

Parent/Guardian #2 Home

Parent/Guardian #2 Cell

Parent/Guardian #2 Email Address

Child's Physician

Physician's Phone

Physician's Fax

Health Insurance

Policy #

Group #

School District

This transmission is for the purpose of referral to the Saratoga County Early Intervention Program. By submitting this referral, it is understood that the information contained may be confidential or privileged and that all information will be handled and protected by Saratoga County per the requirements of all associated federal and state privacy laws.