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Refer My Child

Please answer the following questions to refer your child to Kids Who Count Early Intervention Program.
An intake coordinator will contact you to discuss next steps and schedule an evaluation.

"*" indicates required fields

Child Info

Child's First Name*

Child's Middle Name

Child's Last Name*

Child's DOB*

MM slash DD slash YYYY

Child's Age in Months

Male/Female

Male

Female

Do you live in Nebo School District Boundaries? If no, what district?*

District

Parent/Guardian #1 Info

Parent's/Guardian's #1 First Name*

Parent's/Guardian's #1 Last Name*

Parent's/Guardian's #1 Email Address*

Confirm Email Address

Parent's/Guardian's #1 Home Number*

Parent's/Guardian's #1 Cell Phone*

Parent's/Guardian's #1 Home Address*

Street Address Address Line 2 City State ZIP Code

Parent's/Guardian's #1 Place of Employment*

Parent/Guardian #2 Info

Parent's/Guardian's #2 First Name*

Parent's/Guardian's #2 Last Name*

Parent's/Guardian's #2 Email Address*

Confirm Email Address

Parent's/Guardian's #2 Home Number*

Parent's/Guardian's #2 Cell Phone*

Parent's/Guardian's #2 Home Address

Street Address Address Line 2 City State ZIP Code

Parent's/Guardian's #2 Place of Employment*

Additional Child Info

What type of insurance is your child eligible for?*

What is the family's primary language?

Ethnicity

Race (choose all that apply)

Child's Primary Care Physician Info

Physician Name

Physician Phone

Office Location

Do you have health insurance?*

Yes

No

who is your insurance provider?

How did you hear about Kids Who Count?

What concerns you about your child’s development?*

Fine Motor

Gross Motor

Vision

Hearing

Receptive Language

Expressive Language

Cognitive

Social Emotion

Adaptive

Prematurity

Health

Diagnosed Condition

Other Concerns

Does your child have a diagnosis? If yes, what is the diagnosed condition?

Anything else you'd like us to know before we contact you?

CAPTCHA

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801.423.3000
801.423.3844
345 N. SR 198 Salem, UT 84653

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