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Early Intervention Referral Form

While all children grow and develop in unique ways, some children experience delays in their development. Children in Pennsylvania with developmental delays and disabilities benefit from a state supported collaboration among parents, service practitioners and others who work with young children. Pennsylvania's Early Intervention program provides coaching support and services to families with children, from birth to age five, with developmental delays and disabilities. Early intervention builds upon the natural learning opportunities that occur within the daily routines of a child and their family.

Early Intervention supports services and resources for children that enhance daily opportunities for learning provided in settings where a child would be if they did not have a developmental delay and disability, provides families' independence and competencies, and respects families' strengths, values and diversity. Supports and services are designed to meet the developmental needs of children with a disability, as well as the needs of the family related to enhancing the child's development in one or more of the following areas:

  • Physical development, including vision and hearing
  • Cognitive development
  • Communication development
  • Social or emotional development
  • Adaptive development

Children from birth to age five who have special needs due to developmental delays and disabilities are eligible to receive Early Intervention services.

The services provided to children and their families differ based upon the individual needs and strengths of each child and the child's family. Services may be provided in the child's home, child care center, nursery school, play group, Head Start program, early childhood special education classroom or other settings familiar to the family. Early Intervention supports and services are embedded in typical routines and activities, within the family, community and/or early care and education settings. This approach provides frequent, meaningful practice and skill-building opportunities.

IMPORTANT INFORMATION

The name and email provided below will be recorded when you upload files and submit this form.

First and Last Namerequired
First Name
Last Name
I confirm that I have read and understand the explanation of Early Intervention stated above.required

Referral Form (Basic Information)

 

(Must contain a date in MM/DD/YYYY format). Valid range: Mar 28, 2010 – Mar 30, 2026
What is the child's gender?
Citizenship Status of Child
Is the child adopted?required
Write N/A if this is not appicable to the child.
Is the child in foster care?required
Write N/A if this is not appicable to the child.
Write N/A if you don't have a cell phone number.
This should be an email address that the parent/guardian can receive documents and/or information.
Preferred method of contactrequiredPlease select up to 4 choices
Please select up to 4 choices
Days of Week attendingCheck all that apply
Check all that apply

Documentation of Strategies

As part of the referral process, you have the ability to upload data regarding strategies that have been implemented.

Are you prepared with a document that demonstrates strategies that have been implemented?

Documentation Upload

Attach up to 5 files with a maximum size of 20MB
No file chosen

Additional Questions on Strategies

Do you have screenings to upload?required
Attach up to 5 files with a maximum size of 20MB
No file chosen
This upload is not mandatory, but helpful
Is the parent aware of the referral?required
Must contain a date in MM/DD/YYYY format
Do we have permission to share this referral with other CSIU programs that may be able to provide free services to the family?required
Primary Language(s) in the homerequired
Is an interpreter needed?required

Describing Abilities

CommunicationrequiredCheck all that apply
Check all that apply
Social/CommunicationrequiredCheck all that apply
Check all that apply
BehaviorrequiredCheck all that apply.
Check all that apply.
Gross MotorrequiredCheck all that apply
Check all that apply
Fine MotorrequiredCheck all that apply
Check all that apply
SensoryrequiredCheck all that apply
Check all that apply

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