Referral Form for NYC Early Intervention Services

249-02 Jericho Tpke, Suite 207	Phone:718-635-2404
Floral Park, NY 11001	E-mail: Admin@azchild.com

Referral Form for NYC Early Intervention Services
Please complete the information below to the best of your ability. Unless specifically marked as required, fields may be left blank if the information is not available.

Information submitted through this form is transmitted securely and handled in accordance with HIPAA privacy and security requirements.

If you have any questions or would prefer to complete the referral by phone, please contact A to Z Child Development at (718) 635-2404 or Admin@azchild.com.
Child Information
Child Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Sex
Child Address

Street Address

Street Address Line 2
CityStateZip Code
Parent/Guardian Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Parent/ Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/ Guardian Email
example@example.com
Referrer Information (If Applicable)
Same as Parent/ Guardian
Referrer Name

First NameLast Name
Agency / Organization
Referrer email
example@example.com
The Early Intervention Program (EIP) is a public program funded by NYS and county governments for children under the age of 3 who are either suspected of having or at risk for developmental delays or disabilities. Potentially eligible children must be referred to a county program (for NYC dial 311) to receive EIP services. All EIP services are provided at no cost to parents. Health insurance may be used for approved services. A child's eligibility for the program can be determined only by state-approved evaluators under contract, and all services must be authorized by the county. All needed EI services are identified in collaboration with the parent and must be authorized by the municipality. The municipality will arrange for service providers, considering the individual needs of the child and family, to deliver services authorized by the municipality. When early intervention services are delivered in child care settings or community locations that require a fee, the parent is responsible for paying any associated costs with such access to child care or community locations. A to Z Child Development is approved by New York State and is under contract to provide Early Intervention Services in Queens, Brooklyn and New York Counties.
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Referral Form for NYC Early Intervention Services

Child Information

Parent/Guardian Information

Referrer Information (If Applicable)