Describe the reason for referral:

** Check all that apply:  // REQ

Developmental Concerns

Adaptive

Cognitive

Communication

Motor

Social / Emotional

Sensory: Hearing

Sensory: Vision

If child has sensory concerns:

Did your child pass the Universal Newborn Hearing Screening?

Yes

No

Describe vision concerns: Briefly describe all vision-related concerns

Diagnosed Conditions

Chromosomal disorders: Down Syndrome

Chromosomal disorders: Other

Chronic lung disease (CLD)

Congenital infection that is symptomatic (e.g. HIV)

Inborn errors of metabolism associated with CNS involvement (e.g. maple syrup urine disease and galactosemia)

Infants affected by intrauterine drug exposure requiring treatment or showing evidence of intrauterine growth restriction

Infants showing significant effects of maternal prenatal alcohol abuse (e.g Fetal Alchohol Syndrome)

Intraventricular hemorrhage - Grades III or IV

Lead poisoning, with a lead level of 20 ug/dl or greater

Moderate to severe encephalopathy resulting from insult to the brain

Neurodegenerative Disorders with onset in infancy and early childhood (e.g. adrenoleukodystrophy, TaySachs disease)

Periventricular Leukomalacia (PVL)

Prematurity with birth weight of less than 1200 grams (2 lbs. 10 oz.)

Seizure disorder where seizures are frequent or difficult to control or the underlying condition is associated with frequent cognitive impairement (e.g. infantile spasms)

Sensory Impairments: Blind or visually impaired

Sensory Impairments: Deaf or hard of hearing

Severe congenital malformations (e.g. meningomyelocele and congenital hydrocephalus)

Surgical Necrotizing Entercolitis (NEC)

Other

Biological Factors

Apgar < 6 at 5 min

Birth weight < 1200 grams

Congenital infection

Drug exposed / affected

Exposure to toxic substance

Feeding dysfunction

Genetic Syndrome

Gestational age < 34 weeks

Hearing impairment

Metabolic disorder

Neurological problem

Significant medical problem

Small for gestational age

Vision impairment

Other

Environmental Factors

Disturbance in p/c relations

Inadequate / unsafe conditions

Maternal age < 15 years

Maternal mental retardation

Maternal substance abuse

Prior involvement with PS

Other

Other Factors

Asymptomatic lead intoxication with lead level < 20 ug/dL

Born to an HIV positive mother with no HIV symptoms

Chromosomal

Congenital infection

Exposed to intrauterine drug exposure

Inborn errors of metabolism

Intraventricular hemorrhage

Maternal prenatal drug abuse

Mild congenital malformations

Mild insults to the brain

Neurodegenerative disorders

Prematurity with birth weight between 1200 and 2500 grams

Seizure disorders

Sensory impairments

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