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:

Primary Language of child

Language(s) spoken at home

Is an Interpreter Needed?

Ethnicity:

Race:

Citizenship:

Child's Social Security Number

Is child covered by Private Insurance?

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's Name

Phone Numbers:

Rows	Number	Primary #?
Home Phone
Cell Phone

Parent's Email Address

Title

Parent's Name

Phone Numbers:

Rows	Number	Primary #?
Home Phone
Cell Phone

Parent's Email Address

If yes, please identify:

Address

Home Address

Apt. # & Complex/Development Name

City

Zip

Address Type:

Living Situation:

Are there pets in the home?

What kind of pets?

Other

Does Family have internet access?

School District:

Township

Has the child ever been referred or evaluated by Early Intervention?

Is this referral the result of a Plan of Safe Care?

Is child enrolled in child care or preschool?

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?

How many weeks

Formal Diagnosis?

If yes what

Did the child have a developmental screening prior to the referral to EI?

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

Format: 000-000-0000Format: (000) 000-0000.

Is the family aware of the referral?

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?

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