Early On Michigan
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Early On Referral

Thank you for contacting Early On® Michigan; you have entered the online referral process. A statewide project, we are supported by funds from Part C of the Individuals with Disabilities Education Act (IDEA) through the Michigan Department of Education, Office of Early Childhood Education & Family Services.

The information that is provided will be kept completely confidential. Within ten business days, the family will be contacted by a local Early On staff member from the local school district.

Early On® Michigan is the system of early intervention services for infants and toddlers, birth to three years of age, with disabilities or delays, and their families.

If you have questions about our online referral process, please feel free to contact Early On® toll-free at 1800-EarlyOn (1800-327-5966) or vmeeder@edzone.net. TTY service is also available for the deaf or hard of hearing by calling us directly at 517-668-2505 or by calling the Michigan Relay Center at 1-800-649-3777 for additional assistance.
Referral Form
Required fields in Red
How did you find out about us?
Childcare Provider
Child's Information
First Name:
Last Name:
Date of Birth:
Month: Day: Year:
Grade Level:
Gender:
Was the child premature?
Is the child a twin or triplet?
Has the child had an IEP?
Has the child had an IFSP?
Are there speech and or language concerns?

Do you need an interpreter?  Please state in the description of concerns.
¿Usted necesita a intérprete? Por favor estado en la descripción de preocupaciones.

Description of concerns:
Parent/Legal Guardian Information
Guardianship:
Other:
Parent First Name:
Parent Last Name:
Email:
Home Phone:
 ( ) -
Alternate Phone: ( ) - ext.
What's the best time to call?
Address:
City:
State:
Zip:
School District:
Does the parent have an internet connection?
May we call the parent in the near future to ensure that they were connected with their local Project Find?
May we share the parents contact information with projects that support families?
Your Contact Information
Your relation to the child:
Sibling
Aunt/Uncle
Your First Name:
Your Last Name:
Phone:
 ( ) - ext.
Address:
City:
State:
Zip:
Caller Email:
 
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