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Early On Referral

Thank you for contacting Early On® Michigan; you have entered the online referral process. A statewide project, we are supported by funds from Part C of the Individuals with Disabilities Education Act (IDEA) through the Michigan Department of Education, Office of Early Childhood Education & Family Services.

The information that is provided will be kept completely confidential. Within ten calendar days, the family will be contacted by a local Early On staff member from the local school district.

Early On® Michigan is the system of early intervention services for infants and toddlers, birth to three years of age, with disabilities or delays, and their families.

If you have questions about our online referral process, please feel free to contact Early On® toll-free at 1-800-EarlyOn (1-800-327-5966) or eoreferral@edzone.net. TTY service is also available for the deaf or hard of hearing by calling us directly at 517-668-2505 or by calling the Michigan Relay Center at 1-800-649-3777 for additional assistance.

Do you need an interpreter? Please state in the description of concerns.
¿Usted necesita a intérprete? Por favor estado en la descripción de preocupaciones.
Referral Form
Required fields in Red
How did you find out about us?
Physician/Pediatrician
Hospital
Child Protective Services
Teacher/Education Professional
Childcare Provider
Family Member
Web Site
Advertisement
Other
Child's Information
First Name:
Last Name:
Date of Birth:
Month: Day: Year:
Grade Level:
Gender:
Male
Female
Was the child premature?
Yes
No
Is the child a twin or triplet?
Yes
No
Has the child had an IEP? (Individualized Education Plan)
Yes
No
Unsure
Has the child had an IFSP? (Individualized Family Service Plan)
Yes
No
Unsure
Are there speech and or language concerns?
None
Speech: articulation/pronunciation
Language: the number of words
Both

Please give a detailed description of the child's concern/reason for referral.
Parent/Legal Guardian Information
Guardianship:
Birth Parent
Adoptive Parent
Foster Parent
Legal Guardian
Other:
Parent First Name:
Parent Last Name:
Email:
Home Phone:
 ( ) -
Alternate Phone: ( ) - ext.
What's the best time to call?
In order to send this referral on to the appropriate agency, we need an address. If the child and/or parent does not have a permanent address, please call 1-800-EarlyOn to make this referral.
Address:
We can not use P.O. Box numbers.
City:
State:
Zip:
School District:
Does the parent have an internet connection?
Yes
No
Unsure
May we call the parent in the near future to ensure that they were connected with their local Early On?
Yes
No
May we share the parents contact information with projects that support families?
Yes
No
Your Contact Information
Your relation to the child:
Parent/Legal Guardian
Grandparent
Sibling
Aunt/Uncle
Family Friend
Neighbor
Physician
Teacher/Educator
Childcare Provider
Other:
Your First Name:
Your Last Name:
Phone:
 ( ) - ext.
Fax ( ) -
Address:
City:
State:
Zip:
Caller Email:
Does the family know that you're making this referral:
Yes
No
Is it ok for the family to know that you made this referral:
Yes
No
Remeber me on this computer
Submit Referral
You can also refer by:
Email
Fax
Early On
MDE
Project Find
Early On Training and TA
CCRESA