WV BIRTH TO THREE
Child’s N ame:
Office of Maternal, Child and Family Health
Child’s ID #:
Bureau for Public Health
Date :
Department of H ealth and Human Resources
Information Sharing for Transition Planning
Date:
Dear:
:
In order to p romote smooth tr ansitions for children and their fam ilies, WV Birth to
Three is required to send demographic and pertinent referral information to possible receiving
agen cies four to six months prior to a child’s third birthday. Th is infor mation w ill assist you in
understanding the child’s strengths and needs for support as well as what is important to the
family as you prepare for the 90-D ay Face-to-Fac e Meeting.
Attache d you will find information regar ding:
Child’s name :
Par ent’s nam e:
Address:
Phone number:

Assessm ent r eports (please list):
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Individualized Family Service Plan

Other (please list):
Sincerely,
Service Coordinator
WV Birth to Three
Phone number: