Early Learning Program Early Intervention Referral Early Intervention Referral Early Intervention Referral (Birth to Age 3)This referral form is intended to be used for children ages birth to 3 who are enrolled in the Arizona Early Intervention Program (AzEIP). If the child is not enrolled in AzEIP, please use AzEIP's online form, located at this online address: https://azeip.azdes.gov/AzEIP/AzeipRef/Forms/Categories.aspx As required per AAC R9-13-207 E)(11)(d), referral information will automatically be shared with the following: the Arizona Early Intervention Program (AzEIP) and Department of Health Services Office of Newborn Hearing Screening (Hearing Referrals Only) ASDB Fax: 928-447-5494Type of Referral* Hearing Impairment Vision Impairment Hearing and Vision Impairments Orientation & Mobility Referral Date MM slash DD slash YYYY Your Name First Last PhoneEmail Your Relationship with the ChildReferral Source InformationName of Child First Last Child Birth Date MM slash DD slash YYYY Birth Hospital Male or Female Male Female Mother's Full Name First Last Mother's Birthdate MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Email Primary Person to Contact Home PhoneCell PhoneWork PhonePrimary Contact's Relationship to the Child Home Language DDD Referral Made? Yes No Already Enrolled DDD Contact Name AZEIP Referral Made? Yes No Already Enrolled AZEIP Contact Name Fill out this section for a Hearing ReferralCRS Referral Made? ENT Referral Made? ENT Provider Name Fill out this section for a Vision ReferralOphthalmologist Referral Made? Referred to Other Agency? Referred to Other Specialty? Referral Source InformationAudiologist Name: Hospital/Clinic Date of Evaluation MM slash DD slash YYYY Testing that Determined Hearing Loss (Mark All that Apply): Clicks ABR Tone Bursts / Pips Bone Conduction ASSR Behavioral: VRA BOA Play Conventional Hearing Loss Hearing Loss Confirmed Preliminary Next Appointment MM slash DD slash YYYY Degree of Hearing LossLeft- None -Normal (-10 -15)Slight (16 -25)Mild (26 - 40)Moderate (41 -55)Moderately Severe (56 - 70)Severe (70 - 90)Profound (91+)Right- None -Normal (-10 -15)Slight (16 -25)Mild (26 - 40)Moderate (41 -55)Moderately Severe (56 - 70)Severe (70 - 90)Profound (91+)Type of Hearing LossLeft- None -ConductivePermanent ConductiveMixedSensorineuralNeuropathyRight- None -ConductivePermanent ConductiveMixedSensorineuralNeuropathyAmplification Left Right Anticipated Fitting Date MM slash DD slash YYYY Referral Source InformationOptometrist Name Date of Evaluation MM slash DD slash YYYY Opthamologist Name Date of Evaluation MM slash DD slash YYYY CommentsFile Uploads Drop files here or Select files Accepted file types: gif, jpg, png, bmp, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, rar, tar, zip, Max. file size: 256 MB. HiddenTime Stamp Contact ELP Today! Name Email Address Message Send
