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.


Child's Name: 

Date of Birth: 

Parent/Guardian(s) Name (required)

Gender: Male Female


Language (required)English Spanish Other

Interpreter Needed (required)Yes No

Home Phone (required)





Primary Care Provider (required)

Office Phone: 


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)


Email (required)

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

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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