Child Information Child's Name (last, first) Date of Birth (mm/dd/yyyy) Referral Date (mm/dd/yyyy) GenderMale Female Address Street Apt. # City State Zip Child lives with (both parents, mother, father) *Language spoken at home Interpreter needed? Yes No *Does this child attend childcare or preschool? Yes No If yes, name of childcare/preschool Scheduled days *Are any other agencies working with this child or family? Yes No If yes, please list Parent / Guardian 1 Contact Information Contact information for at least one parent or guardian is required. This information is for the person(s) with whom the child resides. Name (last, first) Email Telephone Home Work Cell Mailing Address Same as child Street or P.O. Box Apt. # City State Zip Relationship to the child Mother Father Foster Relative (specify) Other Parent / Guardian 2 Contact Information Name (last, first) Email Telephone Home Work Cell Parent/Guardian 2 Mailing Address Same address as child Street or P.O. Box Apt. # City State Zip Relationship to Child Mother Father Foster Relative (specify) Are the parents/guardian aware of this referral? Yes No If not, why? Primary Healthcare Provider Primary Provider Name Practice Name Telephone Fax Referral Source Information Please fax any supporting documentation, such as evaluation reports or progress notes, at the time of the referral to 207-624-6661. Name (last, first) Agency Telephone Fax Email How did you hear about CDS? Select One Advocacy Org Child Care Provider DHHS - Child Abuse Prevention and Treatment (CAPTA) DHHS - CSHN - Birth Defects Program DHHS - CSHN - Newborn Bloodspot Program DHHS - CSHN - Newborn Hearing Program DHHS - WIC Head Start/EHS Health Department Homeless Shelter Hospital LEA/School Mental Health Clinics Mobile Health Van Newspaper Article/PSA NICU Physician/Healthcare Provider Poster/Brochure Radio PSA Therapist TV PSA Visited Booth Part C Program/Provider ECSE Program/Provider Unknown Referral Source's Relationship to Child Parent or Guardian Other Relative Friend Childcare Provider Head Start Public School Program Primary Healthcare Provider Hospital Therapist DHHS Other (specify) Reason for Referral Area(s) of Concern: (check all that apply) All Developmental Areas (includes 6 following areas) Speech and Language Cognitive Gross Motor Fine Motor Social / Emotional Adaptive / Self-Help Autism Behavior Child Abuse Prevention and Treatment (CAPTA) Drug Affected Baby Hearing Prematurity Vision Other (specify) Explanation of concern(s) Diagnosis (if any)