Early Intervention Referral Form

EI Referral Guidelines (PDF)

Phone: (585) 753-5437, fax: (585) 753-5259

* Required Fields
Referral Information

Primary Reason for Referral *
Check all that apply - at least one.

Child Information
Guardian #1 Information
Guardian #2 Information
Primary Care Provider (PCP) Information
Child Protective/Foster Care Information
File Attachments

Use this space to upload any relevant/necessary files (such as development screening).

Allowed file types: jpg, gif, png, pdf. Max file size: 5mb.
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