EI Referral

Chester County Department of Mental Health/Intellectual and Developmental Disabilities Infant & Toddler Early Intervention
Is this a CONNECT Referral?*

YesNo
Date of Referral

MonthDayYear
Childs Legal Name as it appears on SS or Insurance Card*

First NameMiddle NameLast Name
Child's DOB:*

MonthDayYear
Months of Age
datediff
If your child is 3 years old or older please contact your local Intermediate Unit for Early Intervention services.

Chester County's Intermediate Unit's contact number is 484-237-5000.
Name of Person completing this form:*
Parent(s)/Guardian(s) Name: (first and last name):
Parent*

Phone Numbers:*

	Number	Primary #?
Home Phone
Cell Phone

Parent

Phone Numbers:

	Number	Primary #?
Home Phone
Cell Phone

Email Address
Do you have internet access?*

YesNoUnknown by Referral Source
Are there pets in the home?*

YesNoUnknown by Referral Source
If yes, please identify:
Address*

Home Address

Apt. # & Complex/Development Name

CityState / Province

Zip
Address Type:

Residential and MailingResidentialMailing
Gender:

MaleFemale
Ethnicity:

HispanicNon-Hispanic
Race:

Black or African AmericanAmerican Indian or Alaska NativeWhiteAsianNative Hawaiian or Other Pacific IslanderOther
Name of person making referral*
Relationship or Association to child
Phone Number*
Is the family aware of the referral?*

YesNo
Has your child ever been referred or evaluated by Early Intervention?*

YesNoUnknown by Referral Source
Is this referral the result of a Plan of Safe Care?*

YesNoUnknown by Referral Source
Is child enrolled in child care or preschool?*

YesNoUnknown by Referral Source
Is child covered by Private Insurance?*

YesNoUnknown by Referral Source
Access or Medical Assistance # (10-digit state ID)
Child's SSN
School District:*
Township*
Living Situation:*

Family HomeKinshipFoster Care HomeShelter
Citizenship:

US CitizenPermanent AlienTemporary AlienRefugeeIllegal AlienRefugee Minor
Primary Language*
Language at home
Interpreter Needed?:

YesNo
Original Source of Referral: (did someone suggest Early Intervention to you)*
Referral Reason:*
Was child born prematurely?

YesNo
How many weeks
Formal Diagnosis?

YesNo
If yes what
Did the child have a developmental screening prior to the referral to EI?

YesNoUnknown by Referral Source
Describe the reason for referral/and specific concerns you may have regarding the child's development:*
If family requests a specific service coordinator please note
Someone will be contacting you within a few business days to schedule an appointment. For children 45 days or less from their 3rd birthday please call the CCIU at 484-237-5000. To make a referral for any county not listed, please call CONNECT at 1-800-692-7288.
Submission ID
Form updated 06/24/2025 1:50 pm
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