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Non Parent Referral - Erie County Early Intervention Program

Does the child live in Erie County, New York?

Please complete all sections if possible. * Mandatory sections are indicated. Form cannot be submitted if those sections are not completed.

Child's Information

Sex
Dominant Language

Names of person with whom the child resides – include first and last names if different from child

Additional Parent contact information if separate from above

If different than child

Race & Ethnicity of the CHILD

Ethnicity
Race

Choose all that apply

Physician & Insurance Information

Medicaid

Reason for Referral

list diagnosis / weeks premature/ birth weight if appropriate

Did parent object to the referral?

Thank you for visiting the Erie County Early Intervention Program. Only children residing in Erie County, New York are eligible for this program. 

Please check with the county the child lives in for available services.