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Online Submission Forms » Birth to 3 Referral Form
Please complete the form for any child believed to need Birth to 3 services and submit to our department. Current eligibility criteria is:

Child must have a developmental delay of at least 25% in one area as noted through Birth to 3 evaluation or other records, or diagnosis with a high probability of a developmental delay, or atypical development (such as asymmetrical movement, variant speech and language patterns, delay in achieving significant interactive milestones).

Eligibility is not based on income guidelines and there is no waiting list.

This is to spread space out
Referral Made By:
Name of Person Making Referral
(include first name, last name and
name of hospital/clinic, if applicable):
Referral's Address
(street address, city, state, zip):
Referral's Contact Phone:
Child's Full Legal Name
(as appears on Birth Certificate):
Child's Address
(street address, city, state, zip):
Child's Date of Birth:
Race:
Sex:
Male
Female
Household Primary Language Spoken:
Primary Contact Phone Number:
Name (Parent 1):
Parent's Address
(if different from child):
Parent's Primary Phone:
Parent's Secondary Phone:
Email Address:
Name (Parent 2):
Parent's Address
(if different from child):
Parent's Primary Phone:
Parent's Secondary Phone:
Email Address:
Guardian/Foster Care Name
(if not living with parents):
Guardian/Foster Care Relationship:
Guardian/Foster Care Relationship Qualifier:
Guardian/Foster Care Address
(street address, city, state, zip):
Guardian/Foster Care Primary Phone:
Guardian/Foster Care Secondary Phone:
Child's Primary Physician:
Physician Phone:
Physician Fax:
Physician Address
(no PO box; street address, city, state, zip):
Was the referred child premature?
Yes
No
Unknown
If premature, gestational age completed:
Reason for Referral/Basic Information on the Child
(choose as many as apply):
Adaptive/Self-Help
Cognitive/Problem-Solving
Fine Motor
Gross Motor
Hearing
Social-Emotional or Behavior
Speech/Language
Vision
Other
Describe in detail the reason for referral based on checkboxes above:
Family's Availability for Scheduling Initial Screening with County Coordinator (Monday-Friday):
Date of Next Well-Child Visit
with Primary Care Physician:
Has any other family member/sibling been served by the Birth to 3 program before?
If yes, please list names:
Please list any additional information/
preferred method of contact (phone, email, text):
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