MONTGOMERYCOUNTYINFANTSAND TODDLERS PROGRAMINTAKE REFERRAL APPLICATION

INSTRUCTIONS: Please carefully complete every applicable section on both pages accurately and fully. All Referrers must complete all questions in Sections 1 through 3 . Professional Referrers may only complete Section 4. Type in “N/A” in non-applicable blocks. Click the correct check box to the right of the appropriate answer. If electronically click on each gray block. If manually, please print legibly and clearly. Please do not leave any answers blank. Any questions please contact the Department at 240-777-3997. Fax back at 240-777-3132.

SECTION 1 -- RESIDENCY ANDAGE ELIGIBILITY QUESTIONS
1. Child lives In Montgomery County? / YES / NO / Child less than34.5 months of age today? / YES / NO
2. What is the child’s DOB? / Child’s Age in months: / Is This A Reactivation (Child Received MCITP svcs. previously? )
SECTION 2 -- CHILD/FAMILY INFORMATION
NOTE: PLEASE ENTER IN CHILD’S LEGAL NAMEAS EXACTLY WRITTEN ON BIRTH CERTIFICATE:
Last Name: / Middle Name: / First Name:
Child’s Address: / Apt. No.:
City: / State: / Zip Code: / APT. Complex Name:
Parent’s E-Mail Address:
Gender: / M / F / Adopted? / YES NO / Foster Care? / YES NO
Hispanic/Latino? Yes No Race: (Choose One or More Races): American Indian/Alaskan Native Asian
Black-African American Native Hawaiian-Other Pacific Islander White
Mother: First Name: / Last Name:
Phone: Home: / Work: / Cell:
Father: First Name: / Last Name:
Phone: Home: / Work: / Cell:
Child lives with: Mother Father Sibling(s) Grandparent(s) Aunt(s)/Uncle(s)) / Nanny / Other
Legal Guardian Foster Parent / Name(s) of Legal Guardian(s) or Foster Parent(s):
Who cares for the Child during daytime? Mother Father Sibling(s) In-Home Care/Nanny Day Care/Out Of Home
Primary Language Spoken in Home (Please list in order of usage): / 1. / EnglishFrenchSpanishAmharicArabicCreoleCroatianCzechEthiopianFarsiFilipinoGermanGreekHebrewHindiItalianPersianPortugueseRussianThaiUrduVietnameseChineseKorean / 2. / EnglishFrenchSpanishAmharicArabicChilneseCreoleCroatianCzechEthiopianFarsiFilipinoGermanGreekHebrewHindiItalianPersianPortugueseRussianTagalogThaiUrduVietnamese
Interpreter Services Required? / YES NO Not Sure
SECTION 3 -- CHILD’S DEVELOPMENTAL/MEDICAL INFORMATION
BirthHospital: / Address (City, State, or Country):
Birth Weight: / lbs. / oz / OR / Grams / Number of Weeks Gestation:
Multiple Birth? / YES NO / Type: / Twin? / Triplet? / Quadruplet? / Quintuplet? / Other?
Child’s Pediatrician’s Name: / Office Name:
Address 1: / Address 2:
City: / State: / Zip Code:
Main Phone: / Fax Number: / E-Mail Address:
Child has: Private Insurance? / YES / NO / Receive Medical Assistance (MA/Chips)?: YES NO
If Yes, Please provide the 11-Digit MA Number here: /

REM Insurance?

/ YES NO
SKIP THIS BOX ONLY --FOR MCITP CENTRAL ADMIN STAFF USE ONLY—PROCEED TO PAGE 2
REFERRAL DATE: / IFSP COMPLETION DATE: / INDEX #:
Primary Reason: Adaptive Cognitive Communication Motor Sensory/Hearing Sensory/Vision
Social Emotional Diagnosed Condition / Risk Factors
Information Taken By: / HOMESCHOOL:
SITE APPLICATION FAXED TO: / DOWN /

EAST

/ MID / UP / EMORY GROVE
Date Faxed:
SECTION 3 –CONTINUED FROM PAGEONE (1)
Child’s Full Name: / Date of Birth:
Have you or the Child received MontgomeryCounty Social Services Assistance? / YES / NO
If Yes, Which Types? SSI WIC CWS Food Stamps Other / If Other, Please describe
Does child have any type of medical diagnosis? YES NO
If so, Which Type: Prematurity? Down Syndrome? Other condition not specified here?
If Other, please describe
If ear infections occur, are they: A.) Occasional? B.)Chronic (Long-Term or Repeated)? Tubes Inserted
Has the Child ever had:
Any Surgery?YES NO List:
Any Vision Tests Completed?YES NO Date: / Location
Hearing Test (Newborn)?YES NO Date: / Location:
Hearing Test (Subsequent)?YES NO Date: / Location:
Medical Evaluation (by Specialist)?YES NO Date: / Location:
Developmental Evaluation?YES NO Date: / Location:
Early Intervention Services? YES NO Date: / Location:
Please describe the concerns you have at this time regarding your Child:
How did you learn about our Program? Pediatrician Other Physician NICU Staff Other Hospital Staff Social Worker Friend Child Care Facility Parent Other Please specify

SECTION 4 -- REFERRER’S INFORMATION (If Other than Parent)

First Name:

/

Last Name:

/

Title:

Relationship to Child: Foster Parent Legal Guardian Physician Social Worker Other Please specify:

Referrer’s Agency Name:

/

Family informed of referral?

/

YES

/

NO

Address1:

/

Address2:

City

/

State

/

Zip Code:

Phone Number:

/

Fax Number:

/

E-Mail Address:

SECTION 5--(FOR MCITP SITE STAFF ONLY) EVIDENCE OF COUNTY RESIDENCY/PROOF OF AGE

Please complete all items

1.EVIDENCE OF BIRTH/PROOF OF AGE:

Type of Verification Document (Check One)
Birth Certificate Birth Registration Baptismal Doc. Church Doc. Hospital Doc. Parent’s Affidavit Physicians’/Midwife Certificate Passport/Visa Other (Please Specify Used): ______
A. Visually Inspected? Yes NO MCITP Provider Signature______Date
B. Copy Placed in EIR? Yes NO MCITP Provider Signature______Date
  1. PROOF OF MONTGOMERYCOUNTYRESIDENCE:

Type of Verification Document (Check One)

Mortgage Current rental lease Current utility bill Other (Please Specify Used):______
A. Visually Inspected? Yes NO MCITP Provider Signature______Date
B. Copy Placed in EIR? Yes NO MCITP Provider Signature______Date
Revised July 23, 2010