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ERIE COUNTY EARLY INTERVENTION INTAKE FAX FORM ATTN:Early Intervention FAX #:8145280702NEW INTIMIDATE:READMITService Coordinator:MCI #:DEMOGRAPHIC INFORMATION Name:Birth Last Name:DOB: Race: Primary

How to fill out early intervention erie pa

How to fill out PA Early Intervention Intake Fax Form

1. Gather required information about the child, including name, date of birth, and contact details.
2. Complete demographic information including the family’s address and primary language spoken.
3. Fill in the parent's information and relationship to the child.
4. Provide details about the child's developmental concerns and areas of delay.
5. Indicate any special services the child is currently receiving, if applicable.
6. Sign and date the form to confirm that the information is accurate.
7. Fax the completed form to the designated Early Intervention agency in your area.

Who needs PA Early Intervention Intake Fax Form?

1. Parents or guardians of children who exhibit developmental delays or disabilities.
2. Healthcare providers or professionals who refer children for early intervention services.
3. Educational staff who identify developmental concerns in young children.

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What is PA Early Intervention Intake Fax Form?

The PA Early Intervention Intake Fax Form is a document used to initiate the early intervention process for children suspected of needing developmental support services in Pennsylvania.

Who is required to file PA Early Intervention Intake Fax Form?

Anyone who is concerned about a child's development, including parents, caregivers, and professionals, is required to file the PA Early Intervention Intake Fax Form.

How to fill out PA Early Intervention Intake Fax Form?

To fill out the PA Early Intervention Intake Fax Form, provide the child’s and parent's information, indicate the concerns regarding development, and include any relevant medical history before faxing it to the appropriate early intervention program.

What is the purpose of PA Early Intervention Intake Fax Form?

The purpose of the PA Early Intervention Intake Fax Form is to request evaluation and possible early intervention services for young children who may have developmental delays or disabilities.

What information must be reported on PA Early Intervention Intake Fax Form?

The information that must be reported on the PA Early Intervention Intake Fax Form includes the child's name, date of birth, parent or guardian contact information, specific developmental concerns, and any previous interventions or assessments.