Early Intervention Intake

Your name

Your email

Child's full name

Today's date

Date of birth of child

Parent's Agreement
YesNo

How did you hear about TRE?

Sex of child (Male, Female etc)

Birth Order (1st twin etc.)

Primary language in the home

Race
African America/BlackAsian/Asian AmericanBiracialCaucasian/White/EuropeanHawaiian/Pacific IslanderIndigenous people/Native American

Latino/a/x or Hispanic
YesNo

County of residence
El PasoParkTeller

School district

Diagnosis

Details about diagnosis

Concerns

Details about concerns

Parent/Guardian name

Address

Family's home phone number

Parent/Guardian cell phone number

Parent/Guardian work phone number

Parent/Guardian email address

Relationship of person filling out this form to the child

Social security number of child.

What kind of insurance does the child have?

Insurance information (Private provider, or Medicaid or Child Health Plan Plus ID Number)

Child's Doctor

Doctor's Practice

Doctor's phone number

Doctor's fax number

File(s)