Get the free EarlySteps Referral Form - Easter Seals

EarlySteps Referral Form SPOT USE ONLY Date Received: Date Intake Coordinator Assigned: Date Entered: Date Acknowledgement Sent: Providers who serve infants/toddlers from birth to age three are required

How to fill out earlysteps referral form

How to fill out earlysteps referral form:

1. Obtain the referral form: The earlysteps referral form can usually be obtained from your child's pediatrician or healthcare provider. You can ask for it during a regular check-up or schedule a separate appointment to discuss your concerns and request the form.
2. Complete the child's information: Start by filling out the child's personal information section on the earlysteps referral form. This typically includes the child's name, date of birth, address, and contact information. Make sure to double-check all the details for accuracy.
3. Provide parent or guardian contact information: The referral form may require you to provide your contact information as a parent or guardian. This is important so that the earlysteps program can reach you and communicate any updates or next steps regarding the referral.
4. Include details about the child's developmental concerns: The earlysteps referral form will usually have a section where you can describe the specific developmental concerns you have about your child. Be as detailed as possible, providing examples and specific observations that lead you to seek assistance.
5. Mention any relevant medical history: If your child has any medical conditions or has undergone previous assessments or evaluations, it is crucial to mention these in the referral form. This additional information can help earlysteps professionals better understand your child's situation and provide appropriate support.
6. Sign and submit the form: Once you have completed all the necessary sections of the earlysteps referral form, review it carefully for any mistakes or omissions. Sign the form as required, indicating your consent and understanding of the referral process. Return the form to the designated earlysteps office or healthcare provider.

Who needs earlysteps referral form:

1. Parents or caregivers with concerns about their child's development: The earlysteps referral form is typically needed by parents or caregivers who have concerns about their child's developmental progress in areas such as speech and language, motor skills, cognitive abilities, or social-emotional development.
2. Healthcare professionals or pediatricians: Healthcare professionals or pediatricians may also need the earlysteps referral form. They use this form to facilitate the referral process and ensure that children who may benefit from early intervention services are connected to the appropriate resources and support.
3. Earlysteps program or service providers: The earlysteps referral form is essential for the earlysteps program or service providers. It serves as the initial communication tool to gather necessary information about the child, their developmental concerns, and the reasons for seeking early intervention services. This form helps them assess the child's needs and determine the appropriate course of action.

For pdfFiller’s FAQs

What is earlysteps referral form?

The earlysteps referral form is a document used to refer a child to an early intervention program for developmental delays or disabilities.

Who is required to file earlysteps referral form?

Parents, caregivers, healthcare providers, educators, or other concerned individuals are required to file the earlysteps referral form.

How to fill out earlysteps referral form?

To fill out the earlysteps referral form, you must provide information about the child's development, medical history, and any concerns you may have.

What is the purpose of earlysteps referral form?

The purpose of the earlysteps referral form is to identify children who may benefit from early intervention services to address developmental delays or disabilities.

What information must be reported on earlysteps referral form?

The earlysteps referral form must include the child's name, date of birth, medical history, developmental concerns, and contact information for the referring individual.

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