ERIE COUNTY EARLY INTERVENTION INTAKE FAX FORM 2026

1. Click ‘Get Form’ to open the ERIE COUNTY EARLY INTERVENTION INTAKE FAX FORM in the editor.
2. Begin by filling out the Demographic Information section. Enter the child's name, birth last name, date of birth, race, primary language, living situation, age, and Social Security Number. Ensure accuracy as this information is crucial for processing.
3. Next, provide details about the parent or guardian. Include their name, phone numbers (home and office), and emergency contact information. This ensures that communication remains seamless.
4. In the Insurance Information section, indicate whether there is insurance coverage or if you are applying under Medical Assistance. Fill in any relevant policy details if applicable.
5. Complete the Referral Details by specifying the referral source and reason for referral. It's important to clarify if the parent or guardian has been informed about this referral.
6. Finally, address Diagnosis Details by selecting any relevant conditions and confirming if a screening has been conducted. Indicate how documentation can be obtained for records.

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