Referral for Delaware County Intermediate Unit
Student Information
First Name:
Last Name:
Date of Birth:
Gender:
--- Select One ---
Male
Female
Race/Ethnicity:
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If Other:
Is Hispanic?
Is primary language English?
Yes
No
If not, what is the student's primary language?
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Will documents need to be translated for the family?
Yes
No
School District of Residence
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Child's Address of Residence
Address:
Address 2:
City:
State:
Select State
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Zip Code:
Home Phone:
Parent/Guardian Information
First Name:
Last Name:
Relationship:
Select Relationship
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Parent/Guardian Address
Same address as above?
Address 1:
Address 2:
City:
State:
Select State
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Zip Code:
Contact Information
Email Address:
Home Phone:
Cell Phone:
Work Phone:
Preferred Contact Method:
No preference
Phone Call
Text Message
Email
Referral Information
Name of Person Referring (First/Last Name):
Phone Number:
Relationship to Child:
Referrer is the child's parent
Name of Agency, Program or Center:
or,
School District
Birth-3
Other
Does the child attend a preschool/daycare
Yes
No
If Yes, list name/address of preschool or daycare:
Days in attendance:
M
T
W
Th
F
Time of day attends:
AM
PM
Full day
Is the family aware of the referral?
Yes
No
If No, state reason:
Is child in foster care?
Yes
No
(If parent) How did you know to contact us?
Concerns/Suspected Disability/Delay - please be as specific as possible, including any specific diagnoses:
Comments:
Date of developmental screen:
PASS
RESCREEN
REFER
NOT SCREENED
Date of speech/language screen:
PASS
RESCREEN
REFER
NOT SCREENED
Date of OT/PT screen:
PASS
RESCREEN
REFER
NOT SCREENED
Date of Vision screen:
PASS
RESCREEN
REFER
NOT SCREENED
Date of Social Emotional screen:
PASS
RESCREEN
REFER
NOT SCREENED
Please check if known
Premature
CYF involvement
Homeless assistance, including shelter housing & doubling up
High lead level exposure
Has this child been evaluated?
Yes
No
If yes, where?
Are records available?
Yes
No
Will records be sent?
Yes
No
MCI ID (if known):
Submit Referral
