EI Referral

Chester County Department of Mental Health/Intellectual and Developmental Disabilities

Infant & Toddler Early Intervention Referral Form

All fields noted with "*" are required to be completed in order to submit a referral. Once the required fields are completed, a blue submission button will be available to submit your referral.

If you are having difficulties submitting the referral on-line, please call 610-344-5948 for assistance
Date of Referral

MonthDayYear
Childs Legal Name as it appears on SS or Insurance Card:
First Name*
Middle Name
Last Name*
Child's DOB:*

MonthDayYear
Age
Difference in Days
Difference in Months
Difference in Years
Floor Difference in Years
MonthSub
Gender:

MaleFemale
Primary Language of child*
Language(s) spoken at home
Is an Interpreter Needed?

YesNo
Ethnicity:

HispanicNon-Hispanic
Race:

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Citizenship:

US CitizenPermanent AlienTemporary AlienRefugeeIllegal AlienRefugee Minor
Child's Social Security Number
Is child covered by Private Insurance?*

YesNoUnknown by Referral Source
Is child covered under Medical Assistance? If so, please share the Medical Assistance Number (10-digit state ID)
Parent(s)/Guardian(s) Name: (first and last name):
Title
Parent*

Phone Numbers:*

	Number	Primary #?
Home Phone
Cell Phone

Parent Email Address
Title
Parent

Phone Numbers:

	Number	Primary #?
Home Phone
Cell Phone

Parent Email Address
If yes, please identify:
Address*

Home Address

Apt. # & Complex/Development Name

CityState / Province

Zip
Address Type:

Residential and MailingResidentialMailing
Living Situation:*

Family HomeKinshipFoster Care HomeShelter
Are there pets in the home?*

YesNoUnknown by Referral Source
What kind of pets?

CatDogOther
Does Family have internet access?*

YesNoUnknown by Referral Source
School District:*
Township*
Has the 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
Original Source of Referral: (did someone suggest Early Intervention to you)*
Referral Reason:*
Describe the reason for referral/and specific concerns you may have regarding the child's development:*
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
If family requests a specific service coordinator please note
Name of person making referral*
Relationship or Association To Child Being Referred
Phone Number for Person Making Referral*
Is the family aware of the referral?*

YesNoUnknown by Referral Source
Someone will be in contact with the child's parent/guardian within a few business days to discuss the referral and 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
For County Staff Only-Direct Referral From Physician, CONNECT, or Community Organization?

YesNo
For County Staff Only-Name of Person completing this form for Direct Referral From Physician, CONNECT, or Community Organization:
Form updated 08/08/2025 8:52 am
Should be Empty: