Early Intervention Referral Form

To make a referral for Early Intervention (Carolina Awesome Steps), please fill out the form below, and click the Send button.

1. CHILD INFORMATION

Date and Time of Referral:

First Name:

Middle Name:

Last Name:

Date of Birth:

Gender:

Address:

Medicaid #:

Other Insurance Information:

2. PARENT INFORMATION

Parent(s)/Guardian:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Primary Language of Family:

Will an interpreter be needed?

3. REASON FOR REFERRAL

Presenting Concerns:

Suspected Developmental Delay

List developmental area(s) of concern:

Condition associated with a high probability of developmental delay

List all medical diagnoses:

Substantiated child maltreatment

CAPTA Referral. The Child Abuse Prevention and Treatment Act (CAPTA P.L. 111-320) requires the South Carolina Department of Social Services to refer infants and toddlers, ages birth to three, with substantiated abuse or neglect, and those affected by substance abuse to the BabyNet Early Intervention System.

Identified as affected by illegal substance abuse or withdrawal from prenatal drug exposure

4. REFERRAL SOURCE

Name:

Title/Agency:

Address:

Phone:

Fax:

Email Address:

How did you hear about us?

Additional info about how you found CFS:

Referral Form