Early Intervention Referral Form

Form Instructions

Required fields are marked with an asterisk.(*)

Please complete the form below to submit an early intervention referral to CONNECT. You can also submit a referral by calling 800-692-7288 or emailing help@connectpa.net.
Early Intervention serves children from birth until the age of beginners (when a child enters school). If your child is already enrolled in school, please contact your local school district for assistance.

Parent /Child Contact Information

Referral Source Information