Parent Infant Partner Program Referral Form

Parent Infant Partner Program Referral Form

RI School for the Deaf
Child's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Parent/ Guardian Name

First NameLast Name
Parent Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Phone Number*
Please enter a valid phone number.
Referring Agency*
Service Coordinator Email*
example@example.com
Date of referral*

MonthDayYear
Date
Primary EI Contact*
EI Phone Number*
Please enter a valid phone number.
Primary language(s) used in the home?*
Briefly describe what is known about the child's use of communication/language. Please include any other relevant information.*
When making a referral please include:*

Release of InformationIFSPAudiological recordsApproprioate medical recordsDevelopment evaluationsOther
File Upload

Cancelof
Upon receipt of this referral, we will reach out to the primary EI contact to acknowledge receipt of the referral. The family will be contacted to schedule an orientation visit. We will review the structure of the PIPP program, and talk
with the family about their priorities with regard to their child’s communication. The PIP program welcomes children using listening, spoken language and visual (ASL) communication. If the family decides to enroll in the PIPP program, We then will reach out to the child’s primary EI provider so PIP can be added to the family’s IFSP.

Points of Contact:

Gia Garzone
RI School for the Deaf
PIPP Program Coordinator
Email: Ggarzone@rideaf.net
VideoPhone: 401-519-6170

Victoria Pfanstiehl
RI School for the Deaf
PIPP Administrative Support Coordinator
vpfanstiehl@rideaf.net
Phone (401) 602-0514