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Illinois Early Intervention Program Referral Fax Back Form - Department Of Healthcare And Family Services

State of Illinois

Department of Healthcare and Family Services

Illinois Early Intervention Program Referral Fax Back Form

PART 1 of 2

Complete Part I upon contacting the family, or when a family cannot be contacted in a timely matter. If the parent/guardian

consented to the release of information in Section 6 of the Standardized Illinois Early Intervention Referral Form to the

primary care provider listed in Section 4 and/or the referral source listed in Section 3, send Part 1 of the Referral Fax Back

Form to the primary care provider and/or the referral source for which consent was provided. If the parent/guardian did not

consent to the release of information to either the primary care provider (PCP) or the referral source, then information cannot

be sent to the entity for which consent was not given.

Date: _____/_____/_____

Child’s Name: ___________________________________________

DOB: _____/_____/_____

Parent/Guardian Name: __________________________________________

Date Referral Received: _____/_____/_____

This child was referred to our Child and Family Connections (CFC) office. The following is the status of that referral:

The family was contacted on (date): _____/_____/_____

A Service Coordinator has been assigned to the family:

Name: __________________________________________

CFC # / Location: _____ / __________________________________________

Phone Number: _____ - _____ - __________

Fax Number: _____ - _____ - __________

E-Mail: __________________________________________

Repeated attempts have been made to contact this family - we were unable to establish contact.

Date final contact attempt made: _____/_____/_____

Please let us know if the family is still interested in having an evaluation for their child.

The family has been contacted and requests that you contact them directly for results.

Date request made by family: _____/_____/_____

The family has declined services at this time.

Date service declined: _____/_____/_____

Additional comments:

Version date August 2013

HFS 652 (N-7-14)

Illinois Early Intervention Program Referral Fax Back Form - Department Of Healthcare And Family Services