Early Intervention Referral Form

EI Referral Guidelines (PDF)

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

* Required Fields
Referral Information
The date that the Referral was created. By default, this is today's date.
The Name of the individual who recommended that a referral to Early Intervention be initiated.
The name of the Agency that initiated the referral to Early Intervention, if any.
A phone number where the Referring Individual can be contacted by County Personnel.
The address of the Referring Individual or Agency, including the zip code.
The type of Referral being made.
If yes, attach copy using the "File Attachments" section at the bottom of this form.
Description of the reason the referral to Early Intervention is being made. See EI Referral Guidelines linked to at top of this page.
Areas of Concern
Child Information
Has the child been diagnosed as Deaf or Hard of Hearing?
The race of the child being referred to Early Intervention.
The primary language that is spoken to the child by caregivers.
Is the child of Hispanic descent?
Is the child currently capable of speaking English?
The address of the child's primary or custodial residency, including the zip code.
The School District in which the child's primary or custodial residence is located.
Healthcare Provider & Insurance
The name of child's primary health care provider, such as their pediatrician.
The phone number of the child's primary health care provider.
Household Members (of child)
Other Details
A synopsis of the medical history of the child, including hospitalizations, surgeries, and diagnoses, if any.
The full name and phone number of caseworker assigned to child, if any.
Any additional comments to be attached to the referral to Early Intervention.
File Attachments
Allowed file types: jpg, gif, png, pdf. Max file size: 5mb.
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