All Referral Forms
To complete a FAXED referral, please print this form: fax referral to CDI
and return via fax to 860-571-6853. You may also fax medical records to provide information related to the child’s development.
To complete an ONLINE referral, please choose the link below that best describes your relationship to the child.
Parent or Guardian or Foster Parent
All Others (such as health or child care providers, friends, or relatives)
Anyone with concerns about a young child’s development may make a referral to the Connecticut Birth to Three System. Only the parent or guardian can accept their child’s referral and schedule a developmental evaluation.
If the child you are referring does not live in Connecticut, or will turn 3 years old within 45 days, do not complete this form. Call 1-800-505-7000 to talk with the Child Development Infoline about other options to address your concerns.
Thank you for making a referral to the CT Birth to Three System!
Privacy Notice: The Connecticut Birth to Three System and the United Way of Connecticut, our contractor, are committed to protecting the privacy of children and families referred for early intervention services and supports under Part C of the Individuals with Disabilities Education Improvement Act (IDEA) 2004. All information related to referral of a child is protected by the federal law entitled, the Family Educational Rights and Privacy Act (FERPA).
Parent Rights, including the right to confidentiality, are described here: http://www.birth23.org/files/Families/ParentRightsBrochure-EN.pdf