Child’s Name:

MONTGOMERY COUNTY INTERMEDIATE UNIT

EARLY INTERVENTION REFERRAL FORM

CHILD AND FAMILY PROFILE

Child’s Name: / Gender: / M / F / Parent Name: / Relationship:
Date of Birth: / Age: / Address:
MA Recipient #: / City/State/Zip:
Does your child have Medical Assistance/Access Card? / Yes / No / Phone (home): / Phone (cell):
Private insurance / Yes / No / Phone (work): / Email:
Referral Date: / Parent Name: / Relationship:
Referral Source: / Address:
Child’s Address: / City/State/Zip:
City/State/Zip: / Phone (home): / Phone (cell):
Phone #: / Phone (work): / Email:
Primary Language: / Primary Language:
Interpreter Needed: / Yes / No
School District of Residence: / School District of Residence:
County of Residence: / County of Residence:
Are there any cultural considerations that are important to your family and that would impact on your child’s education? / Yes No
If yes, please describe:
Other:

For a foster child please provide the following information:

Foster Parent Name:
Parent’s Address:
(If different than above):
Home Phone #: / School District of residence:
Parent’s Work Phone #: / Place of Work:
Email Address: / Cell Phone:
Biological Parents Name(s):
Mailing address:
Phone #: / School district:
Foster Agency Name:
Contact Person’s Name:
Mailing address:
Phone #:
Can the foster family’s address be put on forms? / Yes No
Have the biological parents’ legal rights been terminated? / Yes No

(If parental legal rights have been terminated please attach copy of court documentation)

(If parents can not be located, please attach copies of documentation.)

List people living in the child’s home including:Fluent in English?

Parent(s): / Yes No
Sibling(s) Name and ages: / Yes No
Other relative(s): / Yes No
Au pair: / Yes No
Others: / Yes No

School Information

The Preschool Teacher Input Form must accompany this referral form.

For the Preschool, Nursery School, Day Care or Specialized Programming that your child attends please list the following:

Name of School:
Address:
Phone #:
Director:
Teacher:
Days and hours that child attends:
When did you child begin attending this school?

Please list all other schools and day care programs that your child previously attended including dates of attendance and reason for change in schools.

School/Daycare Program / Dates of Attendance / Reason for Change in School

Referral Information:

The reason you are referring your child to the Early Intervention Department is:
If your child received early intervention services or programs through MH/MR please list the service(s) and the amount of service, i.e. 1 hour a week:
If your child received early intervention services prior to moving into Montgomery County please list the service(s) and amount of service:

What previous evaluations has your child had? Please describe listing the type of evaluation, date, evaluator’s name and test results:

(Also attach a copy of the evaluation report/s)

Type of Evaluation / Date / Evaluator’s Name / Test Results
Have any family members received Special Education Services? / Yes No
If yes, please describe:

Adoption Information:

If the child is adopted, at what age did the child join your family?
Was it a domestic or international adoption?
If it was an international adoption, in what country was the child born?
Birth history – Known (If Yes please fill out the birth history section) / Yes No

Birth History:

Did mother and/or baby have difficulties during pregnancy, labor and delivery? / Yes No
If yes, please describe:

Birth weight:

Was the child premature? / Yes No
If yes how many weeks early?
Was your child placed in neonatal intensive care or high risk nursery after birth? / Yes No
If yes, for how long?
Please describe:
Were mother and baby discharged from the hospital together? / Yes No
If not, please describe:

Medical History:

Vision - Has vision been tested? / Yes No
If Yes results were:
By Whom: Date of Screening:
Does your child wear glasses? / Yes No
Hearing - Has your child’s hearing been tested? / Yes No
If Yes results were:
By Whom: Date of Screening:
Has your child had chronic ear infections? / Yes No
Have tubes been placed? / Yes No
Are they currently in place? / Yes No
If your child has hearing aids and/or FM system please describe:

Does your child have any of the following health problems?

If yes, describe:

Allergies: / Yes No
Asthma: / Yes No
Heart Problems: / Yes No
Epilepsy/Seizures: / Yes No
Cancer: / Yes No
Physical Disabilities: / Yes No
Please describe any other health problems your child has:
Date of most recent health appraisal:
By Whom:

If you child has seen a specialist, please list:

What Type of Physician(s) / When / Note Reason or Diagnosis
Has your child ever had a serious accident? / Yes No

If yes:

Date of Accident:
Please Describe:
Has your child ever been hospitalized? / Yes No

If yes:

Date of Hospitalization:
Please Describe:
Is your child on medication? / Yes No
Please Describe:

General Information

How old was your child when he/she:

Sat without support / months
Walked without help / months
Began to babble / months
Used first word / months

Family Information

It is helpful to know the kinds of activities your child participates in, the people who your child spends time with, and the things your child enjoys doing. This information will be used to plan the Early Intervention services and supports that your child might need. Families have the option to participate and are welcome team members in the evaluation process.

1) Describe the child’s and family’s typical day, for example, care giving routines (playtime and favorite activities) as well as community activities (child care and preschool settings and activities, library, playground, etc.).
2) Are there activities that are challenging for the child and family? This could be either at home, in childcare/preschool settings or during community activities.
3) What are the family’s views of their child’s strengths and does the family have any concerns about the child’s development? Does the child’s other caregivers or teachers have any concerns?
4) What are the family's resources and strengths, including extended family, friends, community groups, resources, etc?
5) If there are concerns, what does the family want to address first?
6) Are there activities and routines in which the family/team would like the child to participate?
7) Are there skills that the family and other caregivers could benefit from learning to assist in the child’s development and participation in everyday routines?
8) Is any information needed to enhance the family’s and/or caregiver’s capacity to assist the child’s development and enhance the family’s participation in everyday activities?

Play

Describe your child’s play with:

Description:
Blocks and construction toys such as Duplos (example – building towers, lining up, building walls, building structures)
Puzzles (type of puzzle and # of pieces)
Dolls and/or action figures, pretend kitchen, dress up, trucks, cars, and trains
Arts and crafts materials
Board games and card games
Play ground equipment (swings, slides, sand box, etc.)
General comments about your child’s play:

Behavior

Does your child exhibit any of the following behaviors?

Overly withdrawn / Yes No
Extreme anxiety / Yes No
Limited eye contact / Yes No
Impulsivity / Yes No
Aggression / Yes No
Short attention/focus / Yes No
Excessive temper tantrums / Yes No
Difficulty with transitions / Yes No
Does your child demonstrate any unusual or atypical behavior? / Yes No
If so, describe:
General comments about your child’s behavior:

Social Skills

Does your child:

Demonstrate an awareness of /interest in other people (e.g. go up to other people and smile)? / Yes No
Engage in parallel play along side a child? / Yes No
Participate in an activity with others (ex. Throw and catch a ball)? / Yes No
Join other children already playing? / Yes No
Initiate play with other children? / Yes No
Play with other children for at least 5 minutes? / Yes No
Have a friend or friends? / Yes No
Engage in simple games with rules? / Yes No
Fight frequently with other children? / Yes No
General comments about your child’s social skills:

Speech and Language

Does your child respond to his/her name? / Yes No
Does you child follow directions:
For routine activities at home?
One step?
Two steps? / Yes No
Yes No
Yes No
How does your child let you know what he/she wants or needs? (Example: gestures, points, use words, take and show you, uses sign language, use sentences, etc.)
Check the reasons your child communicates with you and other people: To greet others To make a comment To protest
My child’s vocabulary is: Excellent Good Basic Limited
My child’s speech is understood by other people: Often Sometimes Rarely
Give examples of words your child has difficulty pronouncing:
Does your child answer questions? / Yes No
Does your child ask questions? / Yes No
Does your child have conversations? / Yes No
Does your child stutter? / Yes No
Does your child drool? / Yes No
Does your child use a pacifier? / Yes No
Does your child suck his/her thumb/fingers? / Yes No
General comments about your child’s communication skills:

Cognitive:

Does your child:

Identify body parts? / Yes No
Identify objects and actions? / Yes No
Identify colors? / Yes No
Identify shapes? / Yes No
Count by rote? / Yes No If yes, to what number?
Identify numbers? / Yes No
Sing the ABC song? / Yes No
Listen when you read a story to him/her? / Yes No
Look at books? / Yes No
Listen to books read to the class or a group? / Yes No
General comments about your child’s readiness or cognitive skills:

Gross Motor

Does your child:

Walk? / Yes No
Run? / Yes No
Trip often? / Yes No
Squat? / Yes No
Jump? / Yes No
Stand on one foot for a second? / Yes No
Walk up and down stairs? If yes, describe: / Yes No
Ride a tricycle? / Yes No
Ride a bike with training wheels? / Yes No
Ride a bike? / Yes No
Throw a playground ball? / Yes No
Catch a playground ball? / Yes No
Kick a playground ball? / Yes No
General comments about your child’s gross motor skills:

Fine Motor

My child is: right handed left handed does not have a dominate hand
My child holds a crayon or marker in his / fist fingers with a mature grasp
Does your child color? / Yes No
Does your child copy lines and a circle? / Yes No
Does your child draw things such as a person or face? / Yes No
Does your child turn a doorknob or wind up toy? / Yes No
General comments about your child’s fine motor skills:

Self Help

Does your child independently:

Drink from a baby bottle? / Yes No
Drink from an open cup? / Yes No
Drink from a straw? / Yes No
Feed self with a spoon? / Yes No
Feed self with a fork? / Yes No
Pull a zipper up and down on a coat or jacket? / Yes No
Does your child wear a diaper? / Yes No
Is your child toilet trained? / Yes No In Process
What clothes can your child take off by him/herself?
What clothes can your child put on by him/herself?
General comments about your child’s self care:

Summary

Additional information I would like to share with the evaluation team:
Date / Parent or Guardian Signature

1Revised 11/11/13