Maryland Infants And Toddlers Program Referral And Feedback Form
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2Maryland Infants and Toddlers Program
Referral and Feedback Form
Please complete this form for referring a child (Birth to 3) to Early Intervention (Part C). Diagnosis of a specific condition or disorder is not necessary for a referral.
To Be Completed by Health Care Provider/Referring Agency:
Parent/Child Contact Information
Child Name: ______________________________________________________________________________________
Date of Birth: ______/______/______
Child Age: (Months) _____________
Gender: M
/
F
Home Address: ____________________________________________________________________________________
City: ____________________________________ State: ___________ Zip Code: ____________________________
Parent/Guardian: _________________________________ Relationship to Child:________________________________
Primary Language: ___________________ Home Phone: __________________ Other Phone: ____________________
Reason(s) for Referral to Early Intervention
(Please check all that apply)
Identified condition or diagnosis (e.g., spina bifida, Down syndrome): _______________________________________
Suspected developmental delay or concern (Please circle areas of concern):
Motor/Physical
Cognitive
Social/Emotional
Speech/Language
Behavior
Other: _____________________
Failed Standardized Developmental Screening Tool (Please indicate screen used and attach screen results)
Ages and Stages
PEDS
Other: ___________________________________________________________
At Risk (Describe risk factors): _____________________________________________________________________
Other (Describe): _______________________________________________________________________________
Referral Source Contact Information
Person Making Referral: ___________________________________________ Date of Referral: ______/_______/_______
Address: _________________________________________City/State: _________________________ Zip: ____________
Office Phone: _____________________ Office Fax: _____________________ E-mail _____________________________
To Be Completed by Parent/Guardian:
Release of Information Consent
I, ______________________________________________ (print name of parent or guardian), give my permission for my
pediatric health care provider (listed above) and the Maryland Infants and Toddlers Program to share and communicate any
and all pertinent information regarding my child, _______________________________________ (print child’s name).
Parent/Legal Guardian Signature: __________________________________________________Date: _____/_____/____
To Be Completed by Early Intervention Program and Returned to Referral Source:
Early Intervention Program Contact Information
Date Referral Received: ______/_______/_______
Attempts to Contact Unsuccessful:
Name of Assigned Service Coordinator: ________________________________________________________________
Office Phone: _______________________ Office Fax: _____________________ E-mail _________________________
Eligible for Early Intervention Services?
Yes
No
Initial Results of IFSP:
(Attach Part II. Section A of IFSP)
Areas of Development to be Addressed:
Cognitive
Expressive Language
Receptive Language
Social-Emotional
Adaptive/Self-Help
Gross Motor
Fine Motor
Initial Services to be Provided:
Special Instruction
Speech/Language Therapy
Occupational Therapy
Physical Therapy
_________________________________________
_____________________________________________
Adapted from The American Academy of Pediatrics Policy Statement: Role of the Medical Home in Family-Centered Early Intervention Services: Early Intervention Referral Form. Pediatrics 2007;120;1153-1158
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