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Early Intervention Program Referral Form - New York CityEarly Intervention Program Referral Form - N

Early Intervention Program Referral Form - New York CityEarly Intervention Program Referral Form - N 2026

Early Intervention Program Referral Form - New York CityEarly Intervention Program Referral Form - N Preview on Page 1

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The document is a DSS Referral Form for Early Intervention Services, which must be completed and submitted within 72 hours of a finding of 'Substantiation' or 'In Need of Services.' It collects essential information about the child, parent/caretaker, and any known health or developmental issues to facilitate referrals to Child Developmental Service Agency (CDSA). The form also requires details on prior assessments, involvement with other agencies, and insurance coverage.

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Click ‘Get Form’ to open the Early Intervention Program Referral Form in the editor.
Begin by entering the 'Date of DSS Referral' and 'Date of DSS Finding' at the top of the form. This information is crucial for tracking purposes.
Fill in the child's details, including their name, date of birth, gender, race, and ethnicity. Ensure accuracy as this information is vital for service eligibility.
Provide the address and telephone number of the child’s family. This will help in establishing communication with relevant agencies.
Complete sections regarding parent/caretaker information, including any known health issues or involvement with other agencies. This context can aid in understanding the family's needs.
Indicate if the child has any diagnosed developmental delays or special needs and provide details about their primary medical provider.
Finally, ensure that all necessary attachments are included before submitting your referral to Early Intervention Services within 72 hours.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is early intervention free in New York?

Talk to your doctor, call 311 and ask for Early Intervention, or visit nyc.gov/health/earlyint. Early Intervention services are confidential, voluntary and free for families,* regardless of income, immigration or insurance status.

In what states is early intervention free?

Programs are available in every state and territory. These publicly funded programs provide services for free or at reduced cost for any child who is eligible.

Is early intervention free in NY?

If your child is not eligible, and is younger than 3, you can enroll them in Early Intervention Developmental Monitoring. This free monitoring program will show you if your child is meeting the goals that are expected for their age.

How to refer to early intervention in NYC?

Families, doctors, and community members can make a referral by: Calling 311 and asking for Early Intervention. Completing the Early Intervention Program Referral Form (Fillable PDF) and faxing it to the Citywide Early Intervention Referral Unit.

Do you pay for early intervention?

Certain early intervention services are free in all states. You may be charged on a sliding scale or through insurance for early intervention services that arent free. You cant be denied services if you cant afford to pay for them.

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How do I become an early intervention provider in NYC?

However, to provide early intervention services, you must be licensed, registered, or certified by the New York State Education Department in one of the fields designated as qualified personnel for the Early Intervention Program. Qualified personnel can be found in regulations 10 NYCRR Section 69-4.1(al)(1)-(28).

Do parents need a doctors referral or a medical diagnosis to contact their early intervention program or their local public school for help?

If you, your childs doctor, or other care provider is concerned about your childs development, ask to be connected with your state or territorys early intervention program to find out if your child can get services to help. If your doctor is not able to connect you, you can docHub out yourself.

Early Intervention Program Referral Form - New York CityEarly Intervention Program Referral Form - N 2026

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