Child and Student Education Referral Form

Contact Name (required)

Street Address (required)

City (required)

State (required)

ZIP/Postal Code (ex. 06108 or 06108-0809) (required)

Phone Number(s) (required)

Email Address (required)

Child's Resident School District

Does the child attend daycare, preschool or school? (required)
---YesNo

If yes, where is the child enrolled?

Referral Source (required)
---ParentPhysicianSocial WorkerTeacherOther

Specific referral source. Please state SPECIFIC referral source (ie: if 'parent' please state 'father' or 'mother').

Referred to (required)
---Early On – Birth up to 3 years old (www.1800EarlyOn.org)Build Up – Special education 3 to 5 years oldChild Find – Special education 5 years up to age 26

Please provide the following contact information

Child's First Name (required)

Child's Last Name (required)

Street Address (required)

City (required)

ZIP/Postal Code (ex. 06108 or 06108-0809) (required)

Phone Number(s) (required)

Child's Date of Birth (required)

Child's Ethnicity (required)

Child's Language (required)

Child's Gender (required)
---MaleFemale

Child Lives With (required)

Parent/Guardian Name (required)

Parent/Guardian Relationship (required)
---ParentFoster ParentCourt-Appointed GuardianOther

If you selected "Other" to the question above, please describe the relationship

Please provide a detailed description of child

What are the concerns for child's development? (required)

Communications: How does child communicate what they want? (required)

Mobility: How does child move about their environment? (required)

Social Skills: How does child interact with others? (required)

Play Skills: How and with what does child like to play? (required)

Eating Skills: How does child eat, and what do they like? (required)

For questions call (734) 334-1393.

This form is intended for children attending Wayne County schools or living in Wayne County ONLY.