Early Start intake form · Stars Assessment Center

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(844) 700-9889 sarcintake@starsinfantprogram.com

Referral

Referred by

Phone

Fax

Reason for referral

Demographic information

Child’s nameRequired

Date of birthRequired

Age

Sex

Language at homeRequired

Ethnicity/RaceRequiredUse the drop-down menu to select your preference

School district

Lives withRequired

Parent Guardian Other

Parent

Parent’s nameRequired

PhoneRequired

AddressRequired

Apt #

City

ZIP code

Language at home

Parent’s date of birth

Emailexample@example.com

Parent #2

Parent #2’s name

Phone

Address

Apt #

City

ZIP code

Language at home

Parent #2’s date of birth

Emailexample@example.com

If the child does not live in the home of the parents

Primary caregiver’s name

Phone

Address

Apt #

City

ZIP code

Language

Placement agency/worker

Date of current placement

Current placement

Foster Other

Who can sign legal consent for the child?

Who holds signing rights for the child?

Physicians

Primary physician name

Phone

Address

Street address line 2

City

State / Province

ZIP code

Other physician

Phone

Address

Street address line 2

City

State / Province

ZIP code

Insurance/financial information

Medical #

Private health insurance

Medical information

Please describe priorities in detail for each category.

Communication

Physical motor: gross and fine

Adaptive/self-help

Social-emotional

Cognitive

Has the child had a hearing evaluation?

Yes No

List significant health problems or diagnoses (including seizures, history of ear infections, feeding problems)

Medications/equipment

Birth information

Length of pregnancy

Birth weight

Additional comments/significant social factors

Please send the most recent well-child exam and any developmental screening (ASQ, M-CHAT) by fax or email.

Fax: (866) 501-8318
Phone: (844) 700-9889
Email: sarcintake@starsinfantprogram.com

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Thank you.

Referral

Demographic information

Parent

Parent #2

If the child does not live in the home of the parents

Physicians

Insurance/financial information

Medical information

Birth information

High risk