To submit a Pennsylvania Early Intervention referral form, use the state’s CONNECT system: fill out the online form at paggdc.powerappsportals.us/EarlyInterventionReferralForm, call 1-800-692-7288, or email help@connectpa.net.1Commonwealth of Pennsylvania. Make a Referral for Early Intervention Services The referral is free, takes a few minutes, and starts the process for any child from birth through age five who may have a developmental delay or diagnosed disability. You do not need a doctor’s diagnosis before you refer. Figuring out whether the child qualifies is what the referral triggers.
Who Can Submit the Referral
Parents are not the only people allowed to refer a child. CONNECT accepts referrals from family members, pediatricians, childcare providers, and anyone else with a concern about a child’s development.1Commonwealth of Pennsylvania. Make a Referral for Early Intervention Services A grandparent, daycare teacher, or doctor can submit the form directly. The form has its own section for the referral source’s contact information so the local program knows who initiated the request and can follow up if needed.
What to Have Ready Before You Open the Form
The online referral form is split into two parts: information about the child and parent, and information about the person making the referral. Collect everything first so you can move through it in one sitting.
For the child and parent, you’ll need:
- Child’s first and last name
- Date of birth in MM/DD/YYYY format
- Gender
- Parent or guardian’s first and last name
- Home address with city, state, zip code, and county
- Phone number
- Email address
- Preferred language for written communication
- Reason for referral
For the referral source, the form asks for:
- Your first and last name
- Practice or office name, if applicable
- Date of referral
- Your address, phone, fax, and email
Pay close attention to the county field. Pennsylvania uses it to route the referral to the correct local early intervention program, so enter the county where the child lives, not where a parent works or where a doctor’s office is located. The preferred-language field controls what language the program uses in written correspondence and whether an interpreter is brought into future meetings, so if the family’s primary language is not English, enter it here.
How to Write the Reason for Referral
Most fields on the form are routine name-and-address entries. The one that deserves thought is the “Reason for Referral” box. Write specific observations instead of general worries. Rather than “he seems behind,” describe what you actually see: “He is 18 months old and does not point at objects or say any words,” or “She is two years old and cannot pull herself to standing.” Name the milestone you expected and what the child is doing instead. If a pediatrician flagged something, say so. If the child has a diagnosed condition, name it.
The intake coordinator reading that box decides how urgently to act and which specialists to involve. Concrete details help match the child with the right evaluators faster.
You don’t need to prove anything in this box. Pennsylvania’s birth-to-three program finds a child eligible with a 25-percent delay, a score of 1.5 standard deviations below the mean in at least one developmental area, or a diagnosed condition likely to cause a delay.3ECTA Center. State and Jurisdictional Eligibility Definitions The areas the program looks at are physical development (including vision and hearing), cognitive development, communication, social or emotional development, and adaptive skills like feeding or dressing.4Central Susquehanna Intermediate Unit. Early Intervention Referral Form A referral is not a request to prove eligibility. It is a request to be evaluated.
Submitting by Phone, Email, or a Local Form
If the online form is not a good fit, call CONNECT at 1-800-692-7288 or email help@connectpa.net.2Pennsylvania Government. Early Intervention Referral Form A CONNECT staff member will collect the same information covered above and enter it into the system. The phone route is helpful for families with limited internet access or anyone who would rather talk through the developmental concerns than type them.
Some Intermediate Units and county programs also publish their own referral forms. These regional forms sometimes ask for more detail. The Central Susquehanna Intermediate Unit’s form, for example, includes sections where you describe the child’s communication, motor, and behavior abilities in more depth.4Central Susquehanna Intermediate Unit. Early Intervention Referral Form The CONNECT form is the most direct route, but a local form reaches the same system.
What Happens After You Submit
CONNECT forwards the referral to the local early intervention program for the child’s county. The local program then assigns a service coordinator to the family as soon as possible. That coordinator becomes your single point of contact. They explain each next step, schedule appointments, coordinate across specialists, and inform you of your legal rights and procedural safeguards.5Commonwealth of Pennsylvania. Infant/Toddler Early Intervention Service Coordination If about two weeks go by with no contact, call CONNECT back at 1-800-692-7288 to confirm the referral was received and routed to the right county.
From there the program may conduct a screening, a quick check using a standardized questionnaire to determine whether a delay is suspected. If a doctor, childcare provider, or social service agency already screened the child before referring, the local program skips straight to evaluation. Children with a diagnosed condition likely to cause a delay also skip screening. And if you want to go directly to evaluation at any point, you can request one. The program must comply even if a screening suggests the child is on track.6Commonwealth of Pennsylvania. EI 12-01 – Screening, Evaluation, and Assessment in Early Intervention
An evaluation is the full assessment, conducted by qualified professionals from at least two disciplines, that determines whether the child actually qualifies for services.6Commonwealth of Pennsylvania. EI 12-01 – Screening, Evaluation, and Assessment in Early Intervention
How Long the Program Has to Act
The deadlines differ by age group, and knowing them helps you tell when the program is behind schedule.
Birth Through Age Two
For infants and toddlers, the local program must complete any screening, the initial evaluation and assessment, and the initial Individualized Family Service Plan meeting within 45 calendar days from the date the program receives the referral.7eCFR. 34 CFR 303.310 – Post-Referral Timeline Pennsylvania follows the 45-day federal requirement without modification, and screening does not pause the clock.8Early Intervention Technical Assistance. Screening, Evaluation, and Assessment in EI The clock starts the day the local infant/toddler program receives the referral, not the day a parent signs a consent form. If you are past the 30-day mark with no evaluation scheduled, follow up.
Ages Three Through Five
For preschool-age children, the evaluation must be completed and a report issued within 60 calendar days after a parent gives written consent for the evaluation.9Disability Rights Pennsylvania. The Right to Special Education in Pennsylvania This 60-day clock runs from your written consent rather than from the referral itself, so signing the consent form promptly starts the deadline sooner. Summer months count.
Consent Comes Next
Submitting the referral is not consent to evaluate. The program needs your separate written consent before it screens your child, evaluates your child, or starts services. Consent means the activity has been fully explained to you in your native language, you agree in writing, and you understand that your agreement is voluntary.10Parent Center Hub. Parent Notification and Consent in Early Intervention You can revoke that consent later, and doing so does not undo what already happened. Expect a consent form to appear after the service coordinator makes contact. That is a normal part of the sequence, not a delay.