Step One Regional Consultation Program
6 Fort St. Quincy, MA 02169
Tel: 617-774-1040
Fax: 617-847-0915

EI REFERRAL FORM

Referring Program_____________________________ Date___________________
Service Coordinator________________________Phone______________________
Coordinator’s Discipline________________________________________________
Child’s Name_______________________________________DPH ID#___________
DOB_____________________________________ Sex____Female ____Male _____

Parents Name________________________________________________________________
Address______________________________________________________________
______________________________________________________________
Phone________________________________Primary Language________________

IFSP Attached____Yes___No
Developmental Assessment Attached___Yes___No

Please describe the reason for the referral (i.e. assistance is needed with obtaining or using adaptive equipment, or staff needs to learn techniques to help include this child in an E.I. community group, or child care etc.)

Child’s Primary Diagnosis______________________________________________
Please describe child’s disability and/or medical needs. Also, attach child’s most recent developmental assessment results.

What medical supports is the child on (if any)?

Does the child use any adaptive equipment or assistive technology? If so, please describe.

What services is the child currently receiving?
Is the child and/or family participating in any community groups within or outside the EI Program? If so, please describe.
Where would you like the initial consultation to take place?

Child’s home

EI Center

Community Setting
Name__________________ Address__________________ Phone____________

Other
Name__________________ Address__________________ Phone____________

I authorize and request the release of information pertaining to my child’s participation in Early Intervention programming to the RCP Coordinator to assist in securing services and program planning for my child and family. I also authorize the RCP staff to speak to and provide written information to my EI Program regarding my child.

Parent Signature __________________________________Date______________

The EI Coordinator may mail or fax this referral to the Step One Regional Consultation Program.