Apply for Early Intervention

Who is filling out this referral form? *ParentHealthcare ProviderOtherName of person filling out form *
Phone number of person filling out form *
Child's First Name *
Child's Middle Name *
Child's Last Name *Gender *MaleFemaleChild's Age (months) *Child's Birth Date *Was this child born premature? *YesNoIf premature, how many weeks early?
Mother/Guardian First Name *
Mother/Guardian Middle Initial
Mother/Guardian Last Name *
Mother's Place of Employment
Father/Guardian First Name *
Father/Guardian Middle Initial
Father/Guardian Last Name *
Father's Place of Employment
Is this child in foster care?YesNoIs your child covered by any of the following:Private InsuranceMedicaidCHIP (Children's Health Insurance Plan)OtherNone at this timeWhat is your child's Medicaid Number:
Do you need assistance accessing health care coverage or other financial assistance (Medicaid / CHIP / WIC )?YesNoEthnicityHispanic or LatinoNot Hispanic or LatinoRaceAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesWhat is the family's primary language?
Name of child's primary doctor?
How did you hear about KOTM?
Have you applied to any other program at Kids on the Move?Early Head StartAutism CenterRespite Care (formerly known as Friday's Kids Respite)Have you ever had a another child in the KOTM Early Intervention Program?YesNo

Contact Information

Address Where Child Resides *
City *
Zip / Postal Code *
Family Email Address
Mother/Guardian Phone Number *
Type of phoneCellHomeOtherDoes texting work for you?YesNoFather/Guardian Phone Number

Concerns

Communication SkillsMy child's language development seems delayed.My child doesn't seem to understand others.My child's words are unclear.OtherSocial SkillsMy child seems overly withdrawn or shy.My child seems have a lack of self-control.My child seems to be too active.My child doesn't not seem to be active enough.It is difficult to keep my child's attention.My child has difficulty following directions.My child has extreme behaviors.OtherMotor SkillsMy child is not sitting up or rolling over.My child is not crawling or pulling to stand.My child is not walking or cruising furniture.My child has trouble holding toys.My child has trouble with picking up small objects.OtherGeneral Healtham concerned about my child's hearing.I am concerned about my child's visionMy child is having trouble eating.My child's sleeping patterns don't seem normal.My child was born premature.My child has a history of ear infections.Other

Medical Diagnosis / Syndrome

Has your child been diagnosed with a specific medical diagnosis or syndrome? (Example: Down Syndrome, Cerebral Palsy, Autism, Attention Deficit Disorder, etc.)YesNo
If yes, please name or describe.
Do you have any additional concerns or is there anything else you would like us to know about your child?