Birth to 3 Program Referral Form – Opportunities, Inc.

Child Information

Child's Full Name:

First

Last

Date of Birth:

Sex

Primary Language (if known):

Child's Race (if known):

Is Child of Hispanic Descent?:

Primary Email Address:

Primary Phone Number:

Parent and/or Guardian's Full Name:

First

Last

Child's Home Address:

City

State/Province

Zip/Postal

County of Child's Residence:

Referring Provider Information

Name of Provider Making Referral:

First

Last

Provider's Address:

City

State/Province

Zip/Postal

Office Phone Number:

Office Fax Number:

Parental Consent to Release Child's Medical, Developmental and Educational Information to Referral Provider

See information below this form for a complete explanation of parental rights regarding consent.

I authorize the provider to disclose medical information to the GREEN VALLEY ENTERPRISES BIRTH TO 3 PROGRAM OF DODGE COUNTY relating to my child's possible developmental delay to assist the Birth to 3 Program to perform its duties and/or to coordinate the delviery of Birth to 3 services to my child. This authorization includes disclosure of information regarding developmental disabilities, mental illness, AIDS or AIDS-related illness, and/or HIV test results, with the following exception(s):

I authorize the county Birth to 3 Program to disclose my child's early intervention record resulting from this referral with the provider as indicated above. The purpose of the disclosure is to assist the Birth to 3 Program to perform its duties and/or to coordinate the Birth to 3 Program services for my child. This authorization includes disclosure described below with the following exception(s):

Unless revoked, the authorization will remain in effect until the expiration time indicated below. (select one):

Authorization expires when my child's participation in the county Birth to 3 Program ends.

Authorization expires one year from the date of my signature on this release.

Authorization expires as of (specify expiration date):Authorization expires as of (specify expiration date):

Parent/Guardian Signature:

Clear

Date Signed:

Printed Name:

Indicate Legal Authority of Person Signing:

Parent of Minor

Legal Guardian

If you are human, leave this field blank.

birth-to-three

referral form

This program is designed for parents to take an active role in their child’s developmental and emotional growth

Child Information

Referring Provider Information

Reason For Referral

Parental Consent to Release Child's Medical, Developmental and Educational Information to Referral Provider

Services

Programs