Please complete all questions below.

Child's First Name: (Mandatory Field):
Child's Last Name: (Mandatory Field):
Child's Date of Birth: (Mandatory Field):
Doctor/Specialist:
Therapist:
IU-O8:
Early Intervention:
Easter Seals:
TSS/BSC:
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:
IEP/IFSP:
Domestic Violence:
Loss of Employment:
Bankruptcy:
Death of family member in household:
Major illness or accident:
Email Address: (Mandatory Field):