Directory Results for East Central Illinois Community Action Agency CHILD AND FAMILY REFERRAL Childs Name: Date: Childs Date of Birth: Site/Classroom: Parent(s) Name: Phone #: Address: Area of Concern Medical/Health Emotional/Behavioral Speech/Language - - - - - to East Central Illinois Community Action Agency CHILD HEALTH HISTORY Childs Name: Childs Date of Birth: Person Interviewed: Relationship to Child: English Spanish Other Fathers Name: Language Used at Home: Mothers Name: Guardians Name: Date -