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Parent Infant Program Referral Form
Birth to Three Services including Parent Advisors; Sign Language Instructors; and Speech Language Pathologists
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* Indicates required question
Date of Referral
*
MM
/
DD
/
YYYY
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Social Security # or Medicaid UID
Your answer
Diagnosis and/or ICD-10 Codes
Your answer
Child's Gender
*
Male
Female
Other:
Primary Custody of Child
*
Parent(s)
State of VT
Other:
Parent/Guardian Name & Address
*
Your answer
Parent/Guardian Email
Your answer
Parent/Guardian Phone
Your answer
Please Select Relationship
*
Mother
Father
Guardian
Other:
Required
CIS Case Manager
Your answer
CIS Case Manager Phone & Email
Your answer
Audiologists Name & Phone Number
Your answer
Services Requested
*
Parent Advisor Home Visits
Sign Language Instruction
SLP Services
Other:
Required
Reason for Referral
Your answer
Please email or fax Insurance Authorization Form; Service Grid and Outcomes Page and any audiology reports or audiograms you have.
Email:
DHHDBESP@gmail.com
(Ileene Therrien)
Fax: (802) 951-1218 (Please direct to Linda Hazard)
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