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.