Early Intervention Referral Form

Select Option A to complete and submit your referral information on this page.
Select Option B to send a previously completed referral form and medical.

A

Click the “Continue” button below the form to start.

B
Send Referral Documents

To send a prefilled referral form or other medical documents for a child, click the 'Send Documents' button below to compose an email and attach the files.

The Early Intervention Program (EIP) is a public program funded by New York State, Nassau, and Suffolk counties, and the NYC Department of Mental Health, and is for children less than three years of age, who have or are suspected of having a developmental delay and/or disability. Eligibility for EIP can be determined only by State aproved evaluators under contract with the municipality. If a child is found eligible for the EIP, all services are identified in collaboration with the family and must be authorized by the municipality.The municipality will arrange for service providers to deliver services authorized by the municipality. All services under the EIP are approved at no out-of-pocket costs for families, but health insurance may be accessed, without affecting your family's benefits. For services provided in community settings that require a fee, the parent is responsible for paying those costs. To access EI services, contact the Nassau County Department of Health at 516-853-3100. To access EI services within New York City, contact the NYC Help Line at 311. Optimal Care Services is an approved provider of Early Intervention services under contract with New York State Department of Health; a New York State Education Department-approved Special Education Itinerant teacher (SEIT) service provider, including bilingual SEIT, Special Education Teacher Support and Services (SETSS); Pendency; and a Continuing Teacher and Leader Education (CTLE) sponsor. The committee on Preschool Special Education (CPSE) program is funded and regulated by the NYS Education Department, county, and your local school district for children 3-5. Services are provided at no direct cost to families for children who meet eligibility guidelines.