Referral to Early Intervention or Early Childhood Special Education Services in Clackamas County

This referral form is designed for community providers to submit referrals when they have a concern with a child's development (such as preschool providers, childcare, home visiting providers). If you are a medical provider, please use the Physician Referral link on our website to access the Universal Referral Form.


Please make a referral with the knowledge and permission of a parent. We cannot share information with you about the status of a referral without a signed Release of Information (ROI). If you want to download an ROI for signature before moving forward with this referral: ROI for Evaluation


Please complete this referral as completely as you are able. You will have the opportunity to upload screenings or other pertinent documents, such as the ROI, at the end of this form.

Referral Source Information

Please enter your information as the referring community partner.

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Please talk to the parent before making a referral to Early Intervention/Early Childhood Special Education services.


While a signed release of information is not necessary to make a referral, it is helpful to exchange information during the referral process or following evaluation.

Phone
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(if different from the referral contact)

Parent/Guardian Information

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Child Information

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Select all that apply.

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Reason for Referral

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If you completed the ASQ or ASQ-SE, Please attach it here. Please also attach any documents that would be helpful for the evaluation. This could include classroom observation or releases of information.

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