Early Development Network Referral Form NOTE: Each child under the age of 3 in a substantiated Child Abuse/Neglect case must be referred to early intervention services through the Early Development Network within two (2) working days after a Status Determination has been made. Date: ____________________ _ Child’s Name ____________________________________________________ _ DOB _____________________ Gender: . Female . Male Child’s Medicaid Number___________________________________________ _ Child’s Current Address _____________________________________________ Phone Number __________________ _ Is child placed with _____ Parent _____ Foster Parent ______ Other ________________________________________ _ Parent/Guardian Name _____________________________________________ _ Address __________________________________________________________ Phone Number __________________ _ Parent/Guardian’s Employer Telephone Number (optional) ________________ _ Child’s Doctor’s Name ______________________________Dr’s Phone Number ______________________________ _ Case Worker Name _________________________________________________ Phone Number __________________ _ Supervisor’s Name _________________________________________________ Phone Number __________________ _ Any developmental concerns: . yes . no If yes, please explain Any medical concerns: . yes . no If yes, please explain Additional comments: Are parents aware of this referral to the Early Development Network? . yes . no What was their response? _______________________________________________________________ ___________________________________________________________________________ _ Worker’s Signature _________________________________________________ Date __________________________ _ ACTION TAKEN ON THIS REFERRAL Receiving Party’s Signature __________________________________________ Date __________________________ _ Title _____________________________________________________________ Phone Number __________________ _ White: Case worker after completion by EDN -Yellow: Early Development Network - Pink: File copy PS-90 NEW 10/04 (53000)