Early Intervention Intake Form Header Image

Thank you for your interest in Preschool Special Education, an early intervention program of the Delaware County Intermediate Unit (DCIU). We’re here to help!

Birth-33 Months

You’ve indicated that your child’s age currently falls between 0-33 months. Our preschool services are currently delivered to students ages 3-6, but we don’t want your concerns to go unheard. Please contact CONNECT at 1-800-692-7288, a service that will connect you to the appropriate Early Intervention provider for children under 3 years of age.


If your child is currently enrolled in Infant Toddler programming please contact your current infant toddler service coordinator for further information.

Children Ages 7+ years old

You’ve indicated that your child’s age currently is over the age of 6. Our preschool services are currently delivered to students ages 3-6, but we don’t want your concerns to go unheard. Please call us directly at 610-938-9000 X6141 and we can help direct you to the appropriate contacts within your school district of residence or view District Special Education websites listed below.

Students with a home district of Chester Upland should contact Elwyn Seeds CONNECT at 1-800-692-7288

How would you like to proceed with the form?

Please provide the following information. Someone from Early Intervention will be in contact with you to schedule a phone call.

Parent Name*
Student Name*
Student Date of Birth*
Please provide the email address where a receipt of this form should be sent.

Parent/Guardian Information

Does child live with both biological parents?*
If no, please provide both addresses of biological parents
Are there custody orders?*
Case Worker Name
Provide DRO (Domestic Relations Order)
No File Chosen
File uploads may not work on some mobile devices.
Parent/Guardian #1 Name*
Parent/Guardian #1 Address*
Parent/Guardian #2 Name
Parent/Guardian #2 Address
Add additional Parent/Guardian Information?*
Parent/Guardian #3 Name
Parent/Guardian #3 Address*
Add additional Parent/Guardian Information?*
Parent/Guardian #4 Name*
Parent/Guardian #4 Address*
Add additional Parent/Guardian Information?*
Parent/Guardian #5 Name*
Parent/Guardian #5 Address*
Add additional Parent/Guardian Information?*
Parent/Guardian #6 Name*
Parent/Guardian #6 Address*

Student Information

Child Name*
Date of Birth*
Gender*
Last 4 Digits only
Does the child have a Medical Assistance/MA/Access Card?*
My child hears or speaks more than one language*
Does the family need/want an interpreter?*
Does the family read English?*
Has your child been previously evaluated for Special Education or Early Intervention Services?*
Date evaluation was completed*
Upload evaluation
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File uploads may not work on some mobile devices.
Does the child attend Head Start or PreK Counts?*
Does the child attend preschool or childcare setting?*
Director/Teacher name*
Days of Attendance*
May we contact school?*
My school/daycare has sent my child home*
My school/daycare has asked my child to leave*
I have withdrawn my child from school/daycare*
Is the child currently in foster care?*
Case Worker name*
Does your child have, or have they ever had, an IFSP or IEP ?*
Upload IFSP or IEP
No File Chosen
File uploads may not work on some mobile devices.

Health and Safety Information

My child is up to date on their well visits with doctor*
My child is up to date on their vaccinations*
My child was born prematurely *
My child was hospitalized in the NICU at birth*
My child has been hospitalized*
My child has been to the ER*
My child takes medication*
My child had/has seizures*
My child had/has asthma*
My child has allergies*
My child is followed by medical specialists*
Does your child have any of the following?*

Concerns/Reason For Referral

Are you concerned about your child's speech and language?*
Are you concerned with your child's Hearing and/or Vision?*
My child's hearing was screened as a newborn*
History of chronic ear infections*
Family history of hearing loss*
Do you have concerns about how your child sees?*
Has your doctor completed a screening of vision?*
Does your child wear glasses?*
Are you concerned about your child's behavior?*
Are you concerned about your child's social and emotional development (playing with others, making friends, etc.)*
Are you concerned about their gross motor skills (e.g. running, jumping)?*
Are you concerned about their fine motor skills (e.g. buttoning, using a crayon)?*
Are you concerned about their self-help skills (e.g. dressing, feeding)?*
Are you concerned with your child's pre-academic skills (e.g. color recognition, letter recognition)*

Child Development and Communication

Does your child use toys to pretend?*
Can your child sit an listen to a short story?*
Can your child name colors correctly?*
Can your child count to 5?*
Can your child retrieve an item in another room when you ask?*
My child uses words to ask for things they want*
My child can answer a where question with words*
My child can follow directions for activities*
I feel that my child understands when I speak to them*
My child speaks clearly for others to understand*
When my child speaks I hear stuttering or stammering*
By themselves, my child can:*
By themselves, my child can: *
By themselves, my child can: *
I sometimes see that my child:*
My child is potty trained*
By themselves, my child can: *
By themselves, my child can: *
By themselves, my child can:*
My child can play next to a peer at home*
My child can listen and play in a group activity*
My child can share toys with other children*
My child can wait for a turn in a game*
My child can separate from parent*
My child will turn and respond when others call their name*
My child will listen to adults to complete an activity*

If you have questions while you are in this portion of the process, please reach out to Michele Shedrick-Johnson| Administrative Assistant, at msjohnson@dciu.org or 610-938-2800 x6503.

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