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Preschool EI Referrals

If you would like to make a referral for a child ages 3-5 and residing within the counties of Clearfield, Clinton, or Centre, please fill out the form below.

Required

Welcome to the CIU 10 Preschool EI referral page.
 
If you have a child between the ages of three and five and are interested in a free screening for speech, developmental, or behavioral concerns, please fill out this form and click "Submit." Shortly thereafter, you will receive a link for an ASQ questionnaire via email. IF YOU DO NOT RECIEVE A LINK WITHIN 24 HOURS, PLEASE CHECK YOUR SPAM FILTER. ASQ packets are also available via USPS.
 
Please type a note in one of the text boxes if you'd like to get an ASQ by USPS mail. If you do not receive the invitation link to fill out the ASQ for your child via email, or you need further assistance, please email Sherry Jesberger at sjesberger@ciu10.org.
Child's Namerequired
First Name
Last Name
Child's Genderrequired
Must contain a date in M/D/YYYY format
If age appropriate, will child be attending Kindergarten this fall?required
Is the parent/guardian aware that a referral is being made for their child? Very often, parents will not complete the paperwork if they do not agree with the referral.required
Reason for Referral (What are the concerns?)required
Does the child have a diagnosis? (ADHD, Autism, etc.) If YES, can you provide a copy of the doctor's report? This helps us in the referral process.required
Has the child ever received early intervention services? required
Does the child attend a preschool/childcare/babysitter?required
What days is the child at preschool/daycare/babysitter? (Please check as many as applicable.)required
Is the child currently enrolled in Early Head Start?required
Is the child currently enrolled in Head Start?required
How did you hear about our program?required
Please enter the name of the person requesting the referral.required
First Name
Last Name