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Early Intervention/Early Childhood Special Education (EI/ELSE) Referral Form for Providers* Birth to Age 5 CHILD/PARENT CONTACT INFORMATION Child s Name: Date of Birth: / / Parent/Guardian Name: Relationship

How to fill out ei-ecse referral_new med statement_06-20-2012x

How to Fill Out EI-ECSE Referral_New Med Statement_06-20-2012x:

1. Carefully read through the instructions provided on the referral form. Familiarize yourself with the required information and any specific guidelines mentioned.
2. Begin by entering the date of the referral in the designated space. Make sure to use the correct format, as specified on the form.
3. Provide the necessary personal details of the individual for whom the referral is being made. This typically includes their full name, date of birth, address, and contact information. Double-check for accuracy to avoid any confusion or delays in processing.
4. Indicate the reason for the referral. Clearly state the concerns or issues that require assessment or intervention. Be concise yet descriptive in explaining the specific needs of the individual.
5. If applicable, provide information about any medical conditions or diagnoses that are relevant to the referral. Include details such as the name of the condition, any medications or treatments being received, and the healthcare professionals involved in their care.
6. If the individual has already undergone assessments or evaluations related to their needs, include a summary of these findings. Provide relevant information from reports or evaluations, such as diagnoses, test scores, or professional recommendations.
7. Complete all sections regarding the educational history and current educational setting of the individual. This may include details about their previous or current school, early intervention services, or any specialized programs they may be enrolled in.
8. If there are any particular concerns or considerations related to the individual's behavior, social skills, or communication abilities, provide specific examples. This can help professionals better understand the individual's needs and develop appropriate interventions.
9. You may be required to attach supporting documentation, such as medical records, diagnostic reports, or previous evaluation reports. Ensure that these documents are organized and clearly labeled to facilitate review and processing.

Who Needs EI-ECSE Referral_New Med Statement_06-20-2012x:

1. Parents or legal guardians who believe their child may require early intervention or special education services.
2. Healthcare professionals who have identified developmental delays or concerns in an individual and wish to refer them for further evaluation or support.
3. Educational professionals who have observed significant learning difficulties or behavioral challenges in a student and require additional assistance in meeting their educational needs.

Overall, anyone involved in the care, education, or support of an individual who may need early intervention or special education services can benefit from filling out the EI-ECSE Referral_New Med Statement_06-20-2012x form.

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What is ei-ecse referral_new med statement_06-20-2012x?

The ei-ecse referral_new med statement_06-20-2012x is a form used to refer a child to Early Intervention/Early Childhood Special Education services.

Who is required to file ei-ecse referral_new med statement_06-20-2012x?

Parents or guardians of children who may require Early Intervention/Early Childhood Special Education services are required to file the ei-ecse referral_new med statement_06-20-2012x.

How to fill out ei-ecse referral_new med statement_06-20-2012x?

The ei-ecse referral_new med statement_06-20-2012x form can be filled out by providing information about the child's medical history, developmental concerns, and any previous evaluations or assessments.

What is the purpose of ei-ecse referral_new med statement_06-20-2012x?

The purpose of the ei-ecse referral_new med statement_06-20-2012x is to initiate the process of determining if a child is eligible for Early Intervention/Early Childhood Special Education services.

What information must be reported on ei-ecse referral_new med statement_06-20-2012x?

Information such as the child's medical history, developmental concerns, and any previous evaluations or assessments must be reported on the ei-ecse referral_new med statement_06-20-2012x.