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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

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?
How did you find out about us? Pediatrician
Department of Health and Human Services
Teacher/Education Professional
Childcare Provider
Family Member
Web Site
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
Child's Ethnicity: American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Two or more races
Hispanic of any race.
Was the child premature? Yes
Is the child a twin or triplet? Yes
The child has current or active IEP? (Individualized Education Plan): Yes
The child has current or active IFSP? (Individualized Family Service Plan): Yes
Are there speech and or language concerns? None
Speech: articulation/pronunciation
Language: the number of words
Are you contacting Early On because you think your child was exposed to lead? Yes
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

Parent Name*:

Parent Email Address*:
Providing an email address will ensure communication with the family about Early On.

 Please check if you DO NOT have an email address

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.

May we call the parent in the near future to ensure that they were connected with their local Early On? Yes
Your Contact Information
Your relation to the child: Parent
Aunt or Uncle
Social Worker
Your Name*:

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

Does the family know that you're making this referral*: Yes
Is it ok for the family to know that you made this referral*: Yes
Remember me on this computer 
You can also refer by:
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Clinton County RESA Logo
Early On Training and TA Logo
Early On Center for Higher Education Logo
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Early On Michigan Foundation Logo
©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.