Get the free Early Intervention Referral Fax Form - PA Department of Health

Early Intervention Referral Fax Form TO: FAX: PHONE: RE:CONNECT 8145422025 8006927288 Early Intervention ReferralParent consent has been provided to share the following information: Parent/Child Contact

How to fill out early intervention referral fax

How to fill out early intervention referral fax

1. To fill out an early intervention referral fax, follow these steps:
2. Obtain the referral fax form from the appropriate source.
3. Fill in the date and your contact information as the referrer.
4. Provide the child's information, including name, date of birth, and address.
5. Include the primary caregiver's information.
6. Specify the reason for referral and provide detailed information about the child's developmental concerns or disabilities.
7. Indicate the services requested and any additional relevant information.
8. Ensure all sections of the form are completed accurately.
9. Sign and date the referral fax.
10. Send the completed referral fax to the appropriate early intervention program or agency.

Who needs early intervention referral fax?

1. Early intervention referral fax is required for individuals or organizations who want to refer a child for early intervention services.
2. This may include healthcare professionals, educators, social workers, parents, or legal guardians who have identified developmental concerns or disabilities in a child and wish to seek early intervention support.

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What is early intervention referral fax?

An early intervention referral fax is a document sent to notify the appropriate authorities about a child's potential need for early intervention services due to developmental delays.

Who is required to file early intervention referral fax?

Professionals in early childhood education, healthcare providers, or any mandated reporters who suspect a child may require early intervention services are required to file this fax.

How to fill out early intervention referral fax?

To fill out the early intervention referral fax, you need to provide information about the child's demographics, the reason for referral, observations regarding the child's development, and your contact information.

What is the purpose of early intervention referral fax?

The purpose of the early intervention referral fax is to initiate the process of evaluating a child's developmental needs and to connect families with appropriate services and support.

What information must be reported on early intervention referral fax?

The information that must be reported includes the child's name, date of birth, address, developmental concerns, the name of the person making the referral, and any relevant observations.