Kirch Developmental Service Center Intake Forms Thank you for your recent request to have your child evaluated by the Kirch Developmental Services Center. To determine whether we can answer the referral question and to help us schedule your child appropriately, you will need to provide us with some very important information. You can do so by returning all the enclosed forms as well as a copy of the report from your child’s most recent EI, preschool or school testing. Because children with developmental concerns should have had an evaluation through one of these systems, we do not typically schedule children without this information. If these evaluations have not yet been completed, the following websites explain the process for requesting an evaluation: www.health.ny.gov/publications/0532.pdf or www.p12.nysed.gov/specialed/publications/policy/parentguide.htm Cover Sheet for Intake Packets - This cover sheet should be sent with all forms listed below. Parent Questionnaire for New Patients (Spanish Version)- This is to be completed to the best of your ability by the parent or legal guardian (If you are not the child’s parent, please include documentation of legal guardianship.). Pre-school/Early Intervention Questionnaire or Educational Questionnaire - School Age - This is to be completed by your child’s teacher, school counselor or therapist. Uniform Referral form - This is intended for your child’s pediatrician/ primary physician. If another physician is referring your child, they can complete the form. You should gather all information (our forms and the test results) and you should send them together to the address on the last page of the Parent Questionnaire. Sending pieces of information separately may delay the review process. We will not review your child’s information until all the necessary documentation is received. Unlike other medical consults, developmental evaluations are usually less urgent and require more input from other sources. We consider the gathering and review of the information outlined above as an essential part of the evaluation process. If you need help gathering this information, consider asking your child’s Service Coordinator, Case Manager, PCP office, or teacher. You can also call 585-275-2986 and ask to speak with our Social Worker for assistance with the paperwork. Once your complete packet of information has been received, it will be reviewed by our Intake team and we will call you. At that time, we will either schedule a Kirch appointment or talk about other options for your child. Sometimes children get referred to our program for problems we are not able to evaluate. When that happens, we do our best to suggest another type of clinic or provider who can better meet your child’s needs. We appreciate your patience during the Intake process and we look forward to talking with you once your information packet has been received. Please be sure to include all telephone numbers where you can be reached during the day.