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 Great Start.

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 up to age three, with disabilities and/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.

Referral Form

Required fields in Red and noted with and asterisks^*.

Does the parent or guardian need an interpreter?
¿El padre o tutor necesita un intérprete? Yes
No

How did you find out about us? Pediatrician
Hospital
Department of Health and Human Services
Teacher/Education Professional
Childcare Provider
Family Member
Web Site
Advertisement
Other

Child's Information

Child's Name^*:

First Name:

Middle Name:

Last Name:

If your child is close to turning age 3, they may be referred to the local special education program.

Date of Birth:

School district where child currently resides:

Gender: Male
Female

Child's Ethnicity: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Hispanic of any race.
Unknown

Was the child premature? Yes
No

Is the child a twin or triplet? Yes
No

The child has current or active IEP? (Individualized Education Plan): Yes
No
Unsure

The child has current or active 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

Are you contacting Early On because you think your child was exposed to lead? Yes
No

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 Name^*:

First Name:

Last Name:

Parent Email Address^*:

Providing an email address will ensure communication with the family about Early On.

Email Address^*:
Please check if you DO NOT have an email address

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.
We can not use P.O. Box numbers.

Address^*:

Street Address:

Street Address 2:

City^*:

Zip Code^*:

May we call the parent in the near future to ensure that they were connected with their local Early On? Yes
No

Your Contact Information

Your relation to the child: Parent
Grandparent
Sibling
Aunt or Uncle
Friend
Social Worker
Physician
Teacher
Childcare
Other:

Your Name^*:

First Name:

Last Name:

Your Phone^*: () - ext.

Your Fax: () -

Your Address^*:

Street Address:

Street Address 2:

City^*:

Zip Code^*:

Your 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

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©2023 Early On^® Michigan · Toll Free: 1-800-Early-On(1-800-327-5966) · Local: (517)668-0185 · TTY: (517)668-2505 · Fax: (517)668-0446
www.1800EarlyOn.org

©2023 Early On^® Michigan · It is the policy of the Clinton County Regional Educational Service Agency (RESA) that no discriminatory practices based on gender, race, religion, color, age, national origin, disability, height, weight, marital status, sexual orientation, political affiliations and beliefs, or any other status covered by federal, state or local law be allowed in providing instructional opportunities, programs, services, job placement assistance, employment or in policies governing student conduct and attendance. Any person suspecting a discriminatory practice should contact the Associate Superintendent for Special Education, 1013 South US-27, St. Johns, MI 48879, or call 989-224-6831.