Early Start Referral Form - Golden Gate Regional Center

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This section is Official Use Only:
Service Coordinator:
Date Packet Sent:
Intake By:
45 Days:
UCI:
Date Assigned:
Check if caller/referrer has been advised to provide reports
GOLDEN GATE REGIONAL CENTER - EARLY START REFERRAL FORM
Child’s LAST Name:
Date of Referral:
Child’s FIRST Name:
Fax
Phone
Email
Parent(s) Name:
Physical Address:
REQUIRED: medical/developmental report attached
Check if parents are aware of and agree to referral
Language(s) Spoken in House:
Foster Parent’s Name: (If applicable)
Sex:
Referrer’s Phone # / Fax # / Email:
Referring Agency/Organization/Source:
Person Making This Referral:
Date of Birth:
Contact Phone #:
Not Fluent in English
Contact Email:
Check if mailing address is different (and list below)
Legal Representative/ Educational Rights:
Birth Hospital:
Other Professional/Agencies Involved (e.g. school district, speech therapist) & Contact Person:
Primary Care Physician:
Child’s Insurance Provider:
please attach any pertinent medical or developmental report to expedite the assessment process
Developmental Delay: Please Elaborate The Delay(s) in Detail:
Cognitive
Physical/ Motor
Vision/ Hearing
Communication
Social/ Emotional
Adaptive/ Self-Help
Established Risk (Specific Diagnosis):
A. High Risk - two of more of the following
Prematurity of less than 32 weeks gestation and/or birth weight of less than 1500 grams
Assisted ventilation of more than 48 hrs during first 28 days
Small for gestational age
Asphyxia neonatorum - with 5 min. Apgar score 0-5
Neonatal seizures or nonfebrile seizures
Central nervous system lesion or abnormality
Central nervous system infection
Multiple congenital anomalies or genetic disorders
Prenatal exposure to known teratogens
Clinically significant failure to thrive
Persistent hypotonia or hypertonia;
Prenatal substance exposure, positive infant neonatal toxicology screen or symptomatic neonatal toxicity or withdrawal.
Severe and persistent metabolic abnormality
Biomedical insult including, but not limited to, injury, accident or illness which may seriously affect development outcome
B. High Risk
Infant or toddler is a child of a person with developmental disability and requires intervention services
Additional Comments/
Other Social Factors:
ATTACH and EMAIL this form & related reports to [email protected] with subject “Early Start Referral” OR FAX it to
1-888-339-3306.
If you have any question, please call 1-888-339-3305 or email [email protected]
APP5A. This form is for referrer(s) use. Jan 2015.
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