Please send this referral to Dawn Larson: Fax: 715-485-8501
Phone: 715-485-8585
100 Polk County Plaza, Suite 180 - Balsam Lake, WI 54810
Child: / DOB: / Sex: £ Male £ Female
Lives with:
£ Parents £ Mother £ Father £ Guardian
£ Other Family Member / Address:
£ Will be changing residency / Home: #:
Other: #:
Cell #:
Other:
£ Parents £ Mother £ Father £ Guardian
£ Other Family Member / Address:
£ Will be changing residency / Home: #:
Other: #:
Cell #:
Referral Source: / Date referral was made:
Physician: / Hospital/Clinic:
Reason for Referral:
Suspected Developmental Delay:
£ Expressive Language (not talking or hard to understand)
£ Receptive Language (understands what is being said to them)
£ Fine Motor (uses fingers & hands)
£ Gross Motor (uses arms & legs)
£ Cognitive (understands & reasons)
£ Social (interacts with others)
£ Adaptive ( performs daily living skills) / Other Possible Concerns:
£ Autism
£ Behavior
£ Feeding
£ Self-Regulation
£ Tone – High (stiff, arching)
£ Tone – Low (floppy like a rag doll)
£ Vision
£ Hearing / Child Protection:
£ Substantiated abuse or neglect
£ Current investigation due to abuse or neglect
£ Receiving voluntary services from CPS
£ NO substantiated abuse or neglect proved, investigation closed, and no voluntary services wanted
Providers Working with the Family: Name of Provider:
£ Child Protective Services
£ Day Care
£ Early Head Start
£ Family Preservation
£ Family Support
£ Public Health
£ St Croix Area Family Resource Center
£ WIC