Get the free EarlySteps Referral Form - Easterseals

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 a copy of the earlysteps referral form from the appropriate agency or organization.
2. Fill out the demographic information accurately, including the child's name, date of birth, address, and contact information.
3. Provide detailed information about the child's developmental concerns or delays. This may include information about their motor skills, language or communication skills, social or emotional development, or cognitive abilities.
4. Include any relevant medical history or diagnoses that may impact the child's development.
5. If applicable, provide information about any previous interventions or services the child has received.
6. Sign and date the referral form, making sure to indicate any necessary consents or releases of information.
7. Submit the completed referral form to the appropriate agency or organization as instructed.

Who needs earlysteps referral form?

1. Earlysteps referral forms are typically needed for children who are suspected to have developmental delays or disabilities. This may include children who are not meeting developmental milestones, showing signs of autism spectrum disorder, experiencing speech or language delays, or exhibiting other concerns in their development. The form is often filled out by parents, guardians, or healthcare professionals who have identified these concerns and believe the child may benefit from early intervention services.

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What is earlysteps referral form?

Earlysteps referral form is a document used to refer a child to the Early Steps program for early intervention services.

Who is required to file earlysteps referral form?

Parents, caregivers, healthcare providers, educators, or any individual concerned about a child's development may file the earlysteps referral form.

How to fill out earlysteps referral form?

The earlysteps referral form can be filled out online or submitted in person at a local Early Steps office. The form requires information about the child's developmental concerns and contact information for the person making the referral.

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 support their development.

What information must be reported on earlysteps referral form?

The earlysteps referral form requires information about the child's age, developmental concerns, and the reason for the referral.