Please complete all questions below.

Child's First Name (Mandatory Field)::
Child's Last Name (Mandatory Field)::
Child's Date of Birth: (Mandatory Field):

What type of therapy (speech, mental health, etc.) and through what agency?:
Early Intervention:
Easter Seals:
IBHS (Intensive Behavioral Health Services):
If IBHS, through what agency?:

Was this a "high risk" pregnancy or any problems at birth? (mom or child):
If "high risk", please explain::

Was the child premature?:
Did the child have a low birth weight?:
Are there documented postpartum/depression issues?:

Was the child referred to our program?:
If referred, by whom?:

Is the child currently enrolled in Early Head Start?:
Is a natural parent in jail/prison?:
Do you have 3 or more children under the age of 5?:
Receiving services from CYS?:
Substance/Drug Abuse:
Domestic Violence:
Loss of Employment:
Death of family member in household:
Major illness or accident:
If your child is enrolled, do you have transportation to and from the center, if needed?:
If parents do not live together, is there a legal custody order in place?:
How did you hear about our program?:

Email Address: (Mandatory Field):