2019-2025 Form

What is the Early Intervention Program Referral Form?

The Early Intervention Program Referral Form is a crucial document used in New York City to initiate the process for evaluating and providing services to children with developmental delays or disabilities. This form is part of a broader initiative aimed at ensuring that young children receive the support they need to thrive. It is typically filled out by parents, guardians, or professionals who suspect that a child may require early intervention services.

How to Obtain the Early Intervention Program Referral Form

The Early Intervention Program Referral Form can be obtained through various channels. It is available online on the official New York City Department of Health and Mental Hygiene website. Additionally, parents and guardians may request a physical copy from local early intervention service providers or community organizations. Ensuring you have the latest version of the form is essential, as updates may occur periodically.

Steps to Complete the Early Intervention Program Referral Form

Completing the Early Intervention Program Referral Form involves several key steps:

• Begin by providing the child's personal information, including their name, date of birth, and address.
• Indicate the reason for the referral, detailing any concerns regarding the child's development.
• Include information about the child's medical history, if applicable, to provide context for the evaluators.
• Sign and date the form to confirm the accuracy of the information provided.

After completing the form, it can be submitted to the appropriate early intervention agency for processing.

Key Elements of the Early Intervention Program Referral Form

Several key elements are essential to the Early Intervention Program Referral Form:

• Child's Information: Basic details about the child, including name and birth date.
• Referral Source: Information about who is making the referral, such as a parent or healthcare provider.
• Developmental Concerns: A section where specific concerns regarding the child's development can be outlined.
• Consent: A signature line for consent to share information with evaluators and service providers.

Legal Use of the Early Intervention Program Referral Form

The Early Intervention Program Referral Form is legally recognized as a formal request for evaluation and services under the Individuals with Disabilities Education Act (IDEA). This law mandates that states provide early intervention services to eligible children. Proper completion and submission of this form ensure that families can access necessary resources and supports for their children, adhering to legal requirements for early intervention services.

Eligibility Criteria

Eligibility for services through the Early Intervention Program is determined based on several criteria:

• Children must be under the age of three at the time of referral.
• There must be documented evidence of developmental delays or disabilities.
• The child must reside in New York City, as the program is specifically tailored for this geographic area.

Once the referral form is submitted, a comprehensive evaluation will be conducted to confirm eligibility and identify appropriate services.