Fillable Early Intervention Program Referral Form (City of New York)

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Early Intervention Program Referral Form (City of New York)

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*The language that the child uses the most. **Can the parent communicate in English?
+
Early Intervention Program Referral Form
Anyone can use this form to refer a child to Early Intervention (EI). • Parents are encouraged to call 311 and ask for
Early Intervention to make referrals. • EI service providers must use the New York Early Intervention System
(NYEIS) to make referrals. • Administration for Children’s Services (ACS) employees and agencies contracted with
ACS must call the Citywide ACS Referral Hotline at 877-885-KIDZ (877-885-5439) to make referrals.
1. REQUIRED INFORMATION
Referral
source
Name:
Referral Date:(MM/DD/YY) ____/____/____
Agency/Facility (if any):
Phone: ( __ __ __ __ __ __) __ __- __ __
Fax: ( ) - __ __ __ __ __ __ __ __ __ __
City:
State:
Zip Code: __ __ __ __ __
Referral Source Type:
Parent/Family
Pediatrician/Doctor
Hospital Community Program
Department of Homeless Services/Shelter Staff Other: _________________________________________
Child Info
Child’s Name:(Last, First)
Date of Birth: (MM/DD/YY) ____/____/___
Race (may select more than one):
White
Black Asian
Native American/Alaskan Hawaiian or Pacific Islander
Ethnicity:
Hispanic Not Hispanic
Gender: Male
Female
Municipality of Residence (Borough):
Dominant Language*:
Family and
Contact Info
Mother’s Name: (Last, First, Middle)
______________________________
Date of Birth: __ __/__ __/__ __
Dominant Language*: ___________
English proficient**? YES NO
Father’s Name: (Last, First, Middle)
____________________________
Date of Birth: __ __/__ __/__ __
Dominant Language*: ___________
English proficient**? YES NO
Alternate Caregiver Contact Name:
______________________________
Relation to Child: Grandparent
Dominant Language*:
Foster Parent Other: ______________
____________
English proficient**? YES NO
Phone: ( __ ______ __ __) __ __- __ __
Address:
Telephone:
Cell (__ __ __) __ __ __- __ __ __ __
- Home (
____ __ __) __ __ __ __ __ __
Work
(__ __ __) __ ____ - __ __ __ __
City: State:
ZIP Code:__ __ __ __ __
Select Only One
REASON FOR REFERRAL
EARLY INTERVENTION: Child with a suspected or
known developmental delay or disability. Fax to
the EIP Regional Office in the child’s borough
of residence:
Brooklyn: 347-396-8817
Manhattan: 212-436-0902 Queens: 718-553-3997
Staten Island: 718-568-2341 Bronx: 718-838-6862
DEVELOPMENTAL MONITORING: Child is developing
typically but may be “at risk” for atypical
development, or child missed or failed newborn
hearing screening.
Fax to the Citywide Developmental Monitoring
Office: 347-396-8869
2.
INFORMED
PARENT/GUARDIAN
CONSENT REQUIRED
Suspected of Delay Primary Referral Reason (EI):
Adaptive Cognitive Communication Physical
Social/Emotional Diagnosis: ________________
Other concerns: _______________________________
At Risk of Delay Referral Reason (DM):
Birth weight: 1,000 – 1,500 grams NICU stay: 10
days or more Parental drug/alcohol misuse
Other (see instructions): _____________________
Child Known to
ACS: Yes No
Child in a Health Home: Yes No Care Management Agency :___________________
Care Manager: ________________________ Phone: (__ __ __) __ __ __- __ __ __ __
Child’s Doctor:
Doctor’s Phone: (__ __ __) __ __ __- __ __ __ __
Birth Hospital:
Location:
Birth Weight: Pounds: ___ ___ Ounces: ___ ____ or Grams: ___ ___ ___ ____Gestational Age: ___ ___
weeks
3. REQUIRES
PARENT
/GUARDIAN
SIGNATURE
Parental Consent to Share and Release Information
I authorize the Early Intervention Program to share: the name and contact information of my service
coordinator the multidisciplinary evaluation (MDE) information about my child’s service plan service
providers assigned to my case with the individuals listed below.
Primary Care Provider: _________________________________________ share info via: Fax: (__ __ __) __ __ __- __
__ __ __
Health Commerce System (HCS) User ID: __ __ __ __ __ __ Mailing Address: ___________________________________________
Other, specify (i.e., Case Worker) __________________________________ share info via: Phone: (__ __ __) __ __ __- __ __ __ __
Fax: (__ __ __) __ __ __- __ __ __ __ Mailing Address:_________________________________________________________________
Parent Signature: _________________________ Date: ______________
“ ”
" "
Questions? Call 311 and ask for "Early Intervention."
EIP 4/2021
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Early Intervention Program Referral Form (City of New York)

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Completed 16 June 2021

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