Early Intervention/Early Childhood Special Education (EI/ECSE

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

Form Rev. 6/2024

CHILD/PARENT CONTACT INFORMATION

Child’s Name: _______________________________________________ Date of Birth: ____/____/____ Gender: M F X

Type of Insurance:  Private OHP/Medicaid TRICARE/Other Military Ins. Other (Specify)___________________  No Ins.

Parent/Guardian 1: Name: ___________________________________________ Relationship to the Child: ______________

Address: ________________________________City: ________________ State: ______ Zip: ______ County: ___________

Primary Phone: _____________________ Secondary Phone: _____________________ E-mail:_________________________

Text acceptable: Yes ( Primary Phone  Secondary Phone)  No Email acceptable: Yes  No

Parent/Guardian 2: Name: ___________________________________________ Relationship to the Child: ______________

Address: ________________________________City: ________________ State: ______ Zip: ______ County: ___________

Primary Phone: _____________________ Secondary Phone: _____________________ E-mail:_________________________

Primary Language: ______________________________________ Interpreter Needed: Yes  No

Child’s Doctor’s Name, Location And Phone (if known): _______________________________________________________

PARENT CONSENT FOR RELEASE OF INFORMATION (more about this consent on page 4)

Consent for release of medical and educational information

I, _________________________________ (print name of parent or guardian), give permission for my child’s health provider

_________________________________ (print provider’s name), to share any and all pertinent information regarding my

child, ____________________________ (print child’s name), with Early Intervention/Early Childhood Special Education

(EI/ECSE) services. I also give permission for EI/ECSE to share developmental and educational information regarding my child

with the child health provider who referred my child to ensure they are informed of the results of the evaluation.

Parent/Guardian Signature: _________________________________________________ Date: ______/______/______

Your consent is effective for a period of one year from the date of your signature on this release.

OFFICE USE ONLY BELOW:

Please fax or scan and send this Referral Form (front and back, if needed) to the EI/ECSE Services in the child’s county of residence

REASON FOR REFERRAL TO EI/ECSE SERVICES

Provider: Complete all that applies. Please attach completed screening tool.

Concerning screen:

 ASQ ASQ:SE  PEDS PEDS:DM M-CHAT SWYC Other:_______________________

Concerns for possible delays in the following areas (please check all areas of concern and provide scores, where applicable):

Speech/Language _______ Gross Motor_______  Fine Motor _______

 Adaptive/Self-Help _______ Hearing _______  Vision _______

 Cognitive/Problem-Solving _______ Social-Emotional or Behavior_______ Other: _____________________

 Clinician concerns but not screened: ______________________________________________________________________________

 Family is aware of reason for referral.

Provider Signature: __________________________________________________ Date: ______/______/______

If child has an identified condition or diagnosis known to have a high probability of resulting in significant delays in development, please complete the attached Physician

Statement for Early Intervention Eligibility (on reverse) in addition to this referral form. Only a physician licensed by a State Board of Medical Examiners may sign the

Physician Statement.

PROVIDER INFORMATION

Name and title of provider making referral: __________________________________ Office Phone: _____________ Office Fax: _________________

Address: _____________________________________________________City: ________________________________ State: ______ Zip: _______

Are you the child’s Primary Care Physician (PCP)? Y___ N___ If not, please enter name of PCP if known: ____________________________________

EI/ECSE EVALUATION RESULTS TO REFERRING PROVIDER

EI/ESCE Services: please complete this portion, attach requested information, and return to the referral source above.

Family contacted on ______/______/______ The child was evaluated on ______/______/_____ and was found to be:

Eligible for services Not eligible for services at this time, referred to: _____________________________________________________________

EI/ECSE County Contact/Phone: _______________________________ Notes:__________________________________________________________

Attachments as requested above: :______________________________________________________________________________________________

Unable to contact parent  Unable to complete evaluation EI/ECSE will close referral on ______/______/______.

* The EI/ECSE Referral Form may be duplicated and downloaded at this Oregon Department of Education web page.

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

Form Rev. 6/2024

MEDICAL CONDITION STATEMENT FOR EARLY INTERVENTION ELIGIBILITY

(

BIRTH TO AGE 3)

Date: __________ Child’s Name: _________________________________________ Birthdate: _________

The State of Oregon, through the Oregon Department of Education (ODE), provides Early Intervention (EI) services

to infants and young children ages birth to three with significant developmental delays. ODE recognizes that

disabilities may not be evident in every young child, but without intervention, there is a strong likelihood a child with

unrecognized disabilities may become developmentally delayed.

ODE is requesting your assistance in determining eligibility for Oregon EI services for the child named above. Under

Oregon law, a physician, physician assistant, or nurse practitioner licensed in by the appropriate State Board can

examine a child and make a determination as to whether he or she has a physical or mental condition that is likely to

result in a developmental delay.

Please keep in mind that, while many children may benefit from Oregon’s EI services, only those in whom significant

developmental delays are evident or very likely to develop are eligible.

Thank you for your time and assistance with this matter.

Medical Condition:

__________________________________________________________________________________________

Please indicate if this child has a:

 Vision Impairment

 Hearing Impairment

 Orthopedic Impairment

Comments:

__________________________________________________________________________________________

Yes



This child has a physical or mental condition that is likely to

result in a developmental delay.

__________________________________________________________________________________________

Physician/Physician Assistant/Nurse Practitioner Date

Print Name: ________________________________________ Phone: ______________________

Please return to: _____________________________________________________________________________________

____________________________________________________________________________________________________

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

Form Rev. 6/2024

OREGON EI/ECSE CONTACTS

Baker County

Phone: 800.927.5847

Fax: 541.966.4800

Douglas County

Phone: 541.440.4794

Fax: 541.440.4799

Lake County

Phone: 541.947.3371

Fax: 541.947.3373

Sherman County

Phone: 541.980.5725

Fax: 1.877.571.3290

Benton County

Phone: 541.704.4011

Fax: 541.704.4010

Gilliam County

Phone: 541.980.5725

Fax: 1.877.571.3290

Lane County

Phone: 541.346.2578

Fax: 541.344.4723

Tillamook County

Phone: 503.842.8423

Fax: 503.842.9663

Clackamas County

Phone: 503.675.4097

Fax: 503.652.4452

Grant County

Phone: 800.927.5847

Fax: 541.966.4800

Lincoln County

Phone: 541.704.4011

Fax: 541.704.4010

Umatilla County

Phone: 800.927.5847

Fax: 541.966.4800

Clatsop County

Phone: 503.338.3345

Fax: 503.325.1297

Harney County

Phone: 541.573.4828

Fax: 541.573.1914

Linn County

Phone: 541.704.4011

Fax: 541.704.4010

Union County

Phone: 800.927.5847

Fax: 541.966.4800

Columbia County

Phone: 503.614.1446

Fax: 503.397.0796

Hood River County

Phone: 541.386.4919

Fax: 541.387.5041

Malheur County

Phone: 541.372.2214 or

541.889.8613

Fax: 541.889.4540

Wallowa County

Phone: 541.927.5847

800.297.5847

Fax: 541.966.4800

Coos County

Phone: 541.266.3915

Fax: 541.269.4548

Jackson County

Phone: 541.494.7800

Fax: 541.494.7829

Marion County

Phone: 503.385.4714

888-560-4666 x4714

Fax: 503.540.2959

Warm Springs

Phone: 541-325-3837

Fax: 541-638-9643

Crook County

Phone: 541.312.1945

Fax: 541.638.9649

Jefferson County

Phone: 541-546-6841

Fax: 541-638-9643

Morrow County

Phone: 800.927.5847

Fax: 541.966.4800

Wasco County

Phone: 541.296.1478

Fax: 541.296.3451

Curry County

Phone: 541.266.3915

Fax: 541.269.4548

Josephine County

Phone: 541.956.2059

Fax: 541.956.1704

Multnomah County

Phone: 503.261.5535

Fax: 503.894.8229

Washington County

English/Spanish: 503.614.1446

Fax: 503.614.1290

Deschutes County

Phone: 541.312.1945

Fax: 541.638.9649

Klamath County

Phone: 541.883.4748

Fax: 541.850.2770

Polk County

Phone: 503.385.4714

888-560-4666 x4714

Fax: 503.540.2958

Wheeler County

Phone: 541.980.5725

Fax: 1.877.571.3290

Yamhill County

Phone: 503.385.4714

888-560-4666 x4714

Fax: 503.540.2958

SOUTHWEST WASHINGTON EI/ECSE CONTACTS

(NOTE: EI/ECSE Program Requirements differ in each state; please contact these offices for Washington Requirements)

Clark County

Phone: 360.750.7507

Fax: 360.906.1010

Cowlitz County

Phone: 360.425.9810

Fax: 360.425.1053

Klickitat County

Phone: 509.281.1281

Fax: 509.493.2204

Skamania County

Phone: 509.281.1281

Fax: 509.427. 0188

Early Intervention/Early Childhood Special Education (EI/ECSE) Referral Form for Providers* Birth to Age 5

Form Rev. 6/2024

CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION BETWEEN

HEALTHCARE PROVIDERS and EARLY INTERVENTION

Information for Parents

This consent for release of information authorizes the disclosure and/or use of your child’s health

information from your child’s health care provider to the Early Intervention/Early Childhood Special

Education (EI/ECSE) program. This consent form also authorizes the disclosure of developmental and

educational information from the Early Intervention/Early Childhood Special Education program to your

child’s health care provider.

Why is this consent form important?

Your child's health care provider sees your child at well-child screening visits and for medical treatment.

Sometimes your child’s health care provider may see the need for more information, like evaluation or

follow up by other specialists, to identify your child’s special health care needs. The Early

Intervention/Early Childhood Special Education (EI/ECSE) program can be a resource to help identify

your child’s needs. The primary goal of this consent form is to allow communication between your child’s

health care provider and EI/ECSE programs so these providers can work together to help your child.

Why am I asked to sign a consent on this form?

The consent allows your child’s health care provider to share information about your child with EI/ECSE,

and allows EI/ECSE to share information about your child with your health care provider. Your consent

for the release of information allows your child’s health care provider and EI/ECSE communicate with

one another to ensure your child gets the care your child needs. However, as your child’s parent or legal

guardian you may refuse to give consent to this release of information.

How will this consent be used?

This consent form will follow your child as he/she is screened and/or evaluated at EI/ECSE. The

information generated by this release will become a part of your child’s medical and educational records.

Information will be shared with only individuals working at or with EI/ECSE or the office of your child’s

health care provider for the purpose of providing safe, appropriate and least restrictive educational

settings and services and for coordinating appropriate health care.

How long is the consent good for?

This consent is effective for a period of one year from the date of your signature on the release.

What are my rights?

You have the following rights with respect to this consent:

 You may revoke this consent at any time.

 You have the right to receive a copy of the Authorization.