Community Referral Form

Washington requirements for ESIT state that individuals, such as primary referral sources, who are in a position to make early intervention referrals shall refer families to a Family Resource Coordinator within seven days of identifying a developmental delay or a disability that could lead to a delay, unless a family requests an extension or that a referral not be made. Learn more about parents' rights for referral from DCYF here.

Community providers and other sources wishing to make a referral on behalf of a family may complete and submit either the web referral form below or download the printable PDF version at this link. PDF Referral Forms and/or any additional documentation can be submitted by email to [email protected] or by fax to 509.544.5798.

Community Source Referral Form

Child is: Under 36 months Over 36 months  (required)

If over 36 months, contact local school district.

Date: 

Child's Name: 

Date of Birth: 

Parent/Guardian(s) Name (required): 

Gender: Male Female

Ethnicity: 

Language (required): English Spanish Other

Interpreter Needed (required): Yes No

Home Phone (required): 

Cell: 

Email: 

Address: 

City: 

Primary Care Provider (required): 

Office Phone: 

Fax: 

Please Check Area(s) of Concern (required):

Cognitive/Problem-Solving Social/Emotional/Behavior Gross Motor 

Fine Motor Speech/Language Adaptive/Self-Help

Hearing Vision Other

If hearing and/or vision is a concern, please additionally refer to a medical specialist for further evaluation.

Specific Concerns/or Diagnosis: 

Referral Source Information:

Name/Agency (required): 

Address (required): 

City (required): 

State (required): 

Zip (required): 

Phone (required): 

Fax: 

Email (required): 

Please send a copy of developmental screen to [email protected] or by fax to (509) 544-5798 if completed.

How did you hear about us (optional)? 

 

NOTE: Upon successful submission of this form, you will be directed to a submission confirmation page and receive a confirmation email to the referral source email entered above. If you do not receive either message, please check that all required fields are entered and try re-submitting the form.



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