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Information/Referral for Services

Main Phone Number: 815-477-4720

Helping Us Grow (HUG) Prevention Initiative Program (Prenatal-3) - ext. 234
Child and Family Connections (CFC) #25 (Birth-3) - ext. 238
Autism Resource Center (ARC) (ASD or suspects ASD)- ext. 225
Neuro Inclusive Counseling (NIC)- ext. 403

 

GENERAL REFERRAL FORM

CHILD'S INFORMATION                           

Has child or sibling been previously enrolled in EI:
Gender
Referred to:
Insurance type:
Please check all that apply

By providing information, you are attesting that either (1) you are your own guardian making a self-referral, (2) you are the youth's parent/guardian or (3) you have consent from the youth's parent/guardian to share this information. In any case, please be aware that the client and/or youth's parent/guardian will be contacted by an agency representative to obtain consent and in order to provide assistance in identifying appropriate services. If you do not provide the parent/guardian's contact information or if a parent/guardian cannot be reached to provide consent, the agency representative will not be able to follow up.

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The program intake coordinator will be contacting you shortly.

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