1.	Date of this referral:*
	mm/dd/yyyy

2.	Referred by:*
	Name and Title:   Phone Number:   Email:   Fax:

3.	Child's Information*
	First and Last Name   Date of Birth   Male or Female

4.	MA NumberThis item is required if the child has medical assistance.

5.	Child's Ethnicity:* Early intervention providers are required to report ethnicity data to insure that all communities are being well served.
	-- Please Select --White/Non-HispanicAsian/Pacific Islander HispanicMiddle East/IndiaBlack/Non-Hispanic Native AmericanUnsure

6.	Parent/Guardian Information Provide as much contact and demographic information as you possibly can so we can confirm county residency and contact the family.
	First and Last Name:   Note here if the child is living with other than birth parent(s):   Address Line 1:   Address Line 2:   City:   State:   Zip Code:   Home Phone:   Work Phone:   Cell Phone:   Parent Email:   County:   School District of Residence:

7.	Does child have a primary language other than English? If yes, what language?*

8.	Reason for Referral/Status at Time of Referral*
	Child screened by the Head Start team and an evaluation is requested. Concerns were noted during the intake process. Other, please specify

9.	Areas of Concern/Diagnosed Disability* Respond below to provide information about the child's suspected needs or identified delays. Select at least 1 and no more than 8.
	Communication Skills    Cognitive Skills (general knowledge, attention, problem solving)    Social/Behavioral    Fine/Gross Motor Skills (movement, physical activity, pre-writing, handling small objects)    Self Help/Adaptive Skills (dressing, eating, toileting, self-care)    Diagnosed with PDD/Autism    Diagnosed with ADD or ADHD    Diagnosed with Vision Impairment    Diagnosed with Hearing Impairment    Diagnosed with Physical Disability    Diagnosed with other educational or medical disability    Diagnosed with Developmental Delay    Other, please specify

10.	Document Status* Identify the documents that have been mailed or emailed to support this referral. Scanned documents can be emailed to preschol@bucksiu.org. Mailed documents should be sent to Early Childhood Services/Intake, Bucks County Intermediate Unit, 705 Shady Retreat Road, Doylestown, PA 18901. Select at least 1 and no more than 8.
	Screening Report    Release/Exchange Form    Other, please specify

11.	Date of Screening:
	mm/dd/yyyy