Bridges4Kids Referrals      *required fields

 

You are making a referral to Bridges4Kids.  In turn, Bridges4Kids will personally supply support or we will refer you to another program, either Early On Michigan or Project Find Michigan, depending upon the child's age.  If you would like to handle the referral yourself, please call 1-800-EarlyOn.

 

IF YOU ARE MAKING A CPS REFERRAL, PLEASE CALL 1-800-EARLYON.

 

Early On serves children in Michigan from birth until their 3rd birthday.  If your child has already reached their 3rd birthday please refer to "Project Find" below. If your child is already receiving special education services, please choose "Bridges4Kids" below.  Changed your mind? Return to earlychildhoodmichigan.org, return to ProjectFindMichigan.org, or return to Bridges4Kids.org. 

 

*Refer to:   

 

*How did you find out about us?

 

Information About Child

First Name

*

Last Name

*

Date of Birth

*
Age
Grade

Gender

Male Female

Is child a twin/triplet? Twin Triplet
Does Child Have a Current IEP? Yes No
Does Child Have a Current IFSP? Yes No
School Child Attends
Your Information (if you are NOT the parent)
Does parent know that you are referring them to us today?
Referral Category
     Other (specify):
First Name
Last Name
Title
Organization/Office
Contact Phone   i.e. 234567890 (no dashes or slashes)
Contact Extension   i.e. 234567890 (no dashes or slashes)
Email Address
Information About Parent
Parent Type *

First Name

 *

Last Name

 *

Street Address

 *

Address (cont.)

City

 *

State/Province

 *

Zip/Postal Code

 - *  i.e. 55555 - 1234
County *
ISD *
Local School District

Home Phone

  *  i.e. 234567890 (no dashes or slashes)
Cell Phone    i.e. 234567890 (no dashes or slashes)

Work Phone

   i.e. 234567890 (no dashes or slashes)
Work Extension   i.e. 23456789  (no dashes or slashes)
Best Time to Call   i.e. before 11 a.m.
Your Email Address *
Information and Concerns About the Child
Please check as many boxes as apply to the child.  Remember, these are things that you would like us to know or that you would like to have investigated or evaluated.  For example, if you are concerned that your child might have autism, but he or she hasn't been diagnosed with autism, you should check the autism box because it is a possible concern.  If your child has been diagnosed with autism, you should also check the autism box.  If your child isn't talking yet, you should check "speech/language" and also let us know if his or her hearing needs to be checked.

Adopted

Attention Problems/ADD/ADHD

Autism

     PDD (Pervasive Developmental Delay)

Asperger's Syndrome

Behavior Problems

Birth Defect

Bullied

Cerebral Palsy

Cognitive Impairment

CPS Referral

Depression

Developmental Delay

Down Syndrome

Drug Abuse by Child

Drug Exposure at Birth

Dyslexia

Failing/Poor Grades

Failure to Thrive

Fetal Alcohol Syndrome (FAS)

Gifted

Hearing Problems - Test Done

Hearing Problems - Test NOT Done

Hyperactivity

Lead Poisoning Concern - Test Done

       BLL Level (If known): 

Lead Poisoning Concern - Test NOT Done

Learning Disability

Low Birth Weight

       Specify Weight (If known): 

Motor Skill Delay - Fine

Motor Skill Delay - Gross

Muscle Tone Poor

Newborn Genetic Screening Abnormality

Premature Birth

       Specify Weeks/Days (If known): 

Sensory Problems

Small for Age

Social Problems

Speech/Language Delay

Vision Problems

Other

       Specify Other: 

Description of Concern:

Please tell us in your own words about your concern or observations.

 

 

Are you sure you're ready to submit this form?

  

Click "Submit" to send information to the database.  Check for errors before clicking "Submit".  Upon clicking "Submit", you will be re-directed to a confirmation page.  If you are not redirected to that page within a few (may take up to 20 seconds) seconds after clicking "Submit", please click the button again to re-send the information.  If you have any problems using this form, contact info@bridges4kids.org with the details.  Upon submitting your referral, you will be directed to a page that you can print for your records. On the first business day following submission, your referral will be processed and forwarded to your local Early On or Project Find coordinator, if applicable.  You should expect to hear from your a service coordinator after the referral.  Project Find referrals placed during the summer will be handled within the first 10 days of the school year. Please allow additional processing time during holidays and weekends. However, if you do not hear from anyone within 10 business days please call 1-800-EarlyOn.