ECI Referral Form…

To download an Adobe Acrobat ECI Referral Form click here

  REFERRAL FORM

 Date: ________________      Completed by:___________________________________

 Child’s Name:______________________________             DOB:_____________

 Child’s Social Security #:__________________________    Sex:     Male /   Female

 Ethnicity:  White  Hispanic  Black       Other:__________________________

 Parent/Caregiver:__________________________    Total Family Members:_____

 Address:________________________________________________________________

                      Street                                                  City                  State                Zip       

Hm Ph#:_________________  Wk#:_________________ Cell Ph#:_________________

Medicaid#:______________________________  CHIP#:_________________________

Medicaid Program:      Parkland    Amerigroup    Texas Health Network    Traditional

Private Insurance Carrier:__________________________________________________

Insured Person’s Employer:____________________________ SSI Recipient: Yes / No

Primary Care Physician:___________________________________  h#:_____________

Referring Person/Agency:_________________________________ Ph#:_____________

Referring Person/Agency Address:___________________________________________

How did you hear about ECI?_______________________________________________

Has parent/guardian been informed that you have contacted ECI?   Yes / No

Referral Reason:  Global   Cognitive   Motor     Speech/Language   Behavior   Vision

Hearing   or    Medical:_______________________ Other:______________________

Special Concerns/Circumstances: ___________________________________________

PLEASE FAX TO:      Attention: Angela Spradlin, RN, Program Director at (903)454-8635    or

EMAIL TO:  Angela Spradlin, RN at  angelas@lrmhmrc.org