Referral Form

School districts provide Early Start services for infants and toddlers (birth to age 3) who have low incidence disabilities (vision, hearing, and orthopedic impairments or a combination of these disabilities). Refer infant and toddlers with other disabilities or at-risk factors to Regional Centers. Regional Centers then refer infants and toddlers with “other” disabilities to school district programs as they deem appropriate.

Questions? Call:
Shannon Romo
Program Specialist
(562) 469-6793

Download Referral Form

Early Start Referral Form

Name of Child
First Middle Last
Child's Birth Date
MM slash DD slash YYYY
Child's Gender
- Female
- Male
Parent / Guardian Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Work Phone
Parent/Guardian Email
Referral Information
Reason for Referral
- Hearing Loss
- Visual Impairment
- Orthopedic Impairment
Date Hearing Loss Identified
MM slash DD slash YYYY
Other Significant Factors
Medical Diagnosis (if any)
Referral to Regional Center
Referral to School District
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Agency
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Early Start Referral Form

Referral Information

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