First Connection Child Early Intervention Referral Request Form
Part C of the Individuals with Disabilities Education Act (IDEA) requires primary referral sources (parents, grandparents, caregivers like daycare workers, and individuals licensed or certified to work with children) to refer any child suspected of having a developmental delay for early intervention as soon as possible but no later than 7 days after a delay is suspected. A child does not have to have a diagnosis to be referred — only a suspected delay identified when a child is missing developmental milestones or has failed a hearing/vision screening.
For assistance in making a referral, call 1-800-643-8258 or 1-501-682-8158. FAX referrals to 1-501-683-4745
To make a referral, please fill out the form below and submit: