Refer a Child

Early Steps Referral / Intake Form

Check all that apply:
- Parent(s) requested referral
- Parent(s) permission obtained for referral
- CAPTA Referral - No screening completed
- CAPTA Referral with screening
- At Risk
- Early Steps
- Unknown
CHILD AND FAMILY INFORMATION
** ALL INFORMATION MARKED WITH AN * MUST BE COMPLETED IN ORDER TO SUBMIT THE REFERRAL**
Child's Name*
Last First
(Also Known As)
(Also Known As)
DOB*
MM slash DD slash YYYY
Primary Language in Home*
Gender*
Do you have a insurance*
Medicaid # / Private Insurance & Policy #*
Ethnic Origin*
Race*
If selected other, specify in here.
Primary Care Physician / Agency
Physician Phone
Physician Fax
Parent/ Caregiver Information
Parent / Primary Caregiver*
Relationship*
Phone Number*
Parent / Caregiver
Relationship
Phone Number
Marital Status
Primary Caregiver Address*
Street Address Address Line 2 City County ZIP / Postal Code
Primary Caregiver Email Address*
Household Size Adults / Children
REASON FOR REFERRAL
Please explain concerns below. (Attach available screening information/ evaluation reports)
File
Max. file size: 300 MB.
How did you hear about Early Steps?
Gross Motor Delay
Fine Motor Delay
Speech Delay
Neurological
Sensory Impairment
Genetic Impairment
Congenital Anomaly
Other
Referred By*
Name - Program/Agency
Phone*
Address
Street Address City State ZIP Code
Email*
Fax
Referral Date
MM slash DD slash YYYY
Primary Care Physician Electronic Signature
By signing as the PCP or other authorized provider, I hereby certify that an Early Intervention referral is medically necessary.
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Early Steps Referral / Intake Form

CHILD AND FAMILY INFORMATION

Parent/ Caregiver Information

REASON FOR REFERRAL