FS-1A · Referral Form

Refer a child for early intervention.

Anyone may submit a referral — a parent, doctor, or caregiver. Required fields are marked with *. We follow up within two business days.

Parent / Child Contact Information

Child's name*

Date of birthGender

Medicaid card #Gestational age (weeks)

Hospital of birth (if known)Child resides withParent / guardian name*Address

Home phoneOther phone

EmailPrimary language at home

Alt. contact (if no phone)Relationship to child

Alt. contact phone

Medical

Currently seen by a NICU program?

Doctor / pediatrician

Doctor phoneDoctor fax

Specialists

Referral Source

Your name*Date of referral

Is the family aware you are making this referral?

Agency namePhone

Your address

FaxYour email

Reason for Referral

Kentucky's Early Intervention System serves children birth to age three with significant developmental delay or medical conditions that put them at risk.

Check all suspected areas of delay or concern:

Describe areas of concernOther concernsHealth concerns

Audiological exam completed?

Diagnosed condition expected to lead to delayICD code(s)

By submitting, you consent to KEIS staff contacting the family about this referral.