Please complete all sections if possible. * Mandatory sections are indicated. Form cannot be submitted if those sections are not completed.
Names of people with whom the child resides. Please include first and last names if different from the child
Choose all that apply
Please include any diagnosis.
I consent to the referral of my child to the Erie County Early Intervention Program. I provide consent to Erie County’s Early Intervention Program to release information regarding the outcome of this referral to
I understand that all information shared with and by the county will be held confidential.
Sign above
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.