Child Demographic
Name of Child:	Date of Birth:
Address:	Is there a confirmed diagnosis? Yes ☐ No ☐ If yes; please list:
Parent/Guardian Demographic
Name	Address	Phone	Legal Guardian
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☐
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Preferred e-mail address:	Who does the e-mail address belong to?

Referral Information:
Child Care Program:
Reason for Referral: Parent/Guardian is aware of above reason for referral: ☐ Yes
Describes the Child’s Strengths (i.e. communication, social, motor skills, etc)
Describe the Child’s Interests (i.e. toys, songs, people, etc.)
Describe strategies that have been used previously to support this child:

I confirm the following:

☐ The parent/guardian understands reason for referral and consents to the above referral

☐ Resource Consultant was consulted regarding referral

☐ Provided information page to parent/guardian

Supervisor/Executive Director Name	Date