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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 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
Do you need an interpreter?
¿Usted necesita a 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:

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:

Home Phone: () -
Alternate Phone: () - ext.

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:

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:

Your Phone: () - ext.
Your Fax: () -
Your Address:

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
Remember me on this computer 
You can also refer by:
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Michigan Department of Education Logo
Clinton County RESA Logo
Early On Training and TA Logo
Early On Center for Higher Education Logo
Build Up Michign Logo
Early On Michigan Foundation Logo
 
©2017 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.