GGDC Portal

An Official Pennsylvania Government Website

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.

Today's Date (MM/DD/YYYY)

*

Parent /Child Contact Information

Child First Name

*

Child Last Name

*

Child Date of Birth (MM/DD/YYYY)

*

Gender

*

Parent Guardian First Name

*

Parent Guardian Last Name

*

Address

*

City

*

State

Zip Code

*

County

Phone (###-###-####)

*

Email

**

Reason for Referral

*

Referral Source Information

Person Making Referral First Name

*

Person Making Referral Last Name

*

Practice/Office

*

Date of Referral (MM/DD/YYYY)

*

Address

*

City

*

State

Zip Code

*

Office Phone (###-###-####)

*

Referral Fax (###-###-####)

*

Referral Email

**

*