EI/ECSE Referral Form | InterMountain ESD

Currently serving Baker, Grant, Morrow, Umatilla, Union, and Wallowa Counties

Referrer Information

Person Making Referral *Required

Email *Required

Phone Number

Agency

Program Name

How did you learn about our services? *Required

Child's Information

Child's Name *Required

First, Middle, and Last

Nickname

Date of Birth *Required

Gender *Required

Male

Female

Parent Information

Father *Required

Mother *Required

Foster Parent(s)

Child Lives With

Both Parents

Father

Mother

Grandparent(s)

Foster Parent(s)

Other

Physical Address *Required

Street, City, State, and Zip

Mailing Address (if different)

Street, City, State, and Zip

Home Phone *Required

Work Phone (Dad)

Work Phone (Mom)

Cell (Dad)

Cell (Mom)

Message Phone

Whose

Demographics

Ethnicity

White

American Indian

Hispanic

Asian

Black

Pacific Islander

Other

Primary Language of Child *Required

Primary Language of Parent(s) *Required

Interpreter Needed

Yes

Preschool Information

Attends Preschool

Yes

Name of Preschool

Teacher

Attends

Monday

Tuesday

Wednesday

Thursday

Friday

Time

Prior EI/ECSE Services

Has child ever received EI or ECSE services? *Required

Yes

If so, where?

When

Name of Program

Program Contact Person

Program Phone

Areas of Concern

Areas of Concern *Required

Cognitive

Social

Behavior

Sensory/Self Help

Vision

Fine Motor

Gross Motor

Language & Communication

Audiology/Hearing

Explanation of Checked Concerns *Required

Medical Information

Medical Condition(s) Diagnosed by Physician

Child's Doctor

Clinic

Phone

Fax

Address

Street, City, State, and Zip

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