For children from birth to age 3, this referral will be sent to Early Intervention for ME. Child Information Child's NameÌýÌý(last, first) Date of BirthÌýÌýÌý(³¾³¾/»å»å/²â²â²â²â) Referral DateÌýÌýÌý(³¾³¾/»å»å/²â²â²â²â) Gender²Ñ²¹±ô±ðÌýFemale Ìý Ìý Address StreetÌýApt. #Ìý CityÌýStateÌýZipÌý Child lives withÌýÌý (both parents, mother, father) *Language spoken at homeÌý Interpreter needed? ÌýYesÌýÌýÌýÌýNo *Does this child attend childcare or preschool?ÌýYesÌýÌýÌýNo If yes, name of childcare/preschoolÌý Scheduled daysÌý *Are any other agencies working with this child or family? ÌýYesÌýÌýÌýNo Ìý If yes, please listÌý Parent / Guardian 1 Contact Information Contact information for at least one parent or guardian is required. This information is for the person(s) with whom the child resides. NameÌýÌý(last, first) EmailÌý TelephoneÌýÌý ÌýHomeÌýÌýWorkÌýÌýCell Mailing AddressÌýÌýSame as child StreetÌýor P.O. BoxÌýApt. #Ìý CityÌýStateÌýZipÌýÌýÌý Relationship to the child ÌýMotherÌýÌýFatherÌýÌýÌýFosterÌýÌýRelativeÌý(specify)ÌýOther Parent / Guardian 2 Contact Information NameÌýÌý(last, first) EmailÌý TelephoneÌýÌý ÌýHomeÌýÌýWorkÌýÌýCellÌý Parent/Guardian 2 Mailing Address ÌýSame address as childÌýÌý Street or P.O. BoxÌýÌýApt. #Ìý CityÌýÌýÌýÌýStateÌýÌýÌýÌýZipÌý Relationship to ChildÌýMotherÌýÌýFatherÌýÌýÌýFosterÌýÌýRelativeÌý(specify)Ìý Are the parents/guardian aware of this referral?ÌýÌýYesÌýÌýÌýNo ÌýIf not, why?Ìý Ìý Ìý Primary Healthcare Provider Primary Provider NameÌý Practice NameÌý TelephoneÌýÌý FaxÌýÌý Referral Source Information Please fax any supporting documentation, such as evaluation reports or progress notes, at the time of the referral toÌý207-624-6661. NameÌýÌý(last, first) AgencyÌý TelephoneÌýÌý FaxÌýÌý EmailÌý How did you hear about CDS?ÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýSelect OneÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýAdvocacy OrgÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýChild Care ProviderÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýDHHS - Child Abuse Prevention and Treatment (CAPTA)ÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýDHHS - CSHN - Birth Defects ProgramÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýDHHS - CSHN - Newborn Bloodspot ProgramÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýDHHS - CSHN - Newborn Hearing ProgramÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýDHHS - WICÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýHead Start/EHSÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýHealth DepartmentÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýHomeless ShelterÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýHospitalÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýLEA/SchoolÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýMental Health ClinicsÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýMobile Health VanÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýNewspaper Article/PSAÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýNICUÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýPhysician/Healthcare ProviderÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýPoster/BrochureÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýRadio PSAÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýTherapistÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýTV PSAÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýVisited BoothÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýPart C Program/ProviderÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýECSE Program/ProviderÌýÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌý ÌýÌýUnknownÌýÌý Ìý ÌýÌý ÌýÌý ÌýÌý ÌýÌý Ìý Referral Source's Relationship to ChildÌýÌýParent or GuardianÌýOther RelativeÌýFriendÌýÌýChildcare ProviderÌýÌýHead StartÌýÌýPublic School ProgramÌýÌýPrimary Healthcare ProviderÌýÌýHospitalÌýÌýTherapistÌýÌýDHHSÌýÌýOther (specify)ÌýÌý Reason for Referral Area(s) of Concern: (check all that apply)ÌýAll Developmental Areas (includes 6 following areas) ÌýSpeech and LanguageÌýCognitiveÌýGross MotorÌýFine MotorÌýSocial / EmotionalÌýAdaptive / Self-HelpÌýAutismÌýÌýBehaviorÌýÌýChild Abuse Prevention and Treatment (CAPTA)ÌýDrug Affected BabyÌýHearingÌýPrematurityÌýVisionÌýÌýOther (specify)Ìý Explanation of concern(s)Ìý Diagnosis (ifÌýany)