Early Intervention

Referral form

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

Insurance

Medical assistance

Private insurance

* Phone

Email address

Alternate contact

Alternate phone

* Caregiver name

Caregiver relationship

Address (Child's)

City (Child's)

State (Child's)

* ZIP (Child's)

* School district

* Reason for referral

Who referred you?

DateReceived

Additional notes