Early Intervention

Note: Fields marked with an asterisk * are required. Having difficulty with this form? Please call (724) 228-6832.

* Child's First Name

* Child's Last Name

Child's Gender

* Date of Birth

Ethnicity

Dentist

Pediatrician

* Medical Assistance

* Private Insurance

Medical Assistance Number

* Phone Number

Contact Email Address

Alternate Contact Name

Alternate Phone

* Caregiver Name

Caregiver Relationship

* Address (Child's)

City (Child's)

State (Child's)

* Zip Code (Child's)

* School District

* Reason for Referral

Who Referred You?

Additional Notes