Contact Us
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Contact tiny-k Early Intervention Douglas County
1.
Child's Name
*
First
Middle
Last
2.
Date of Birth
*
mm/dd/yyyy
3.
If premature, how many weeks at birth?
4.
Child's sex
*
Child's sex
*
Female
Male
Intersex
5.
Child's Race
*
mark all applicable if 2 or more
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
6.
Child's Ethnicity
*
Child's Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
7.
Child's Insurance
*
We are a non-profit and do not require families to pay for services. We will bill Medicaid if appropriate.
Child's Insurance
*
We are a non-profit and do not require families to pay for services. We will bill Medicaid if appropriate.
Private Insurance
KanCare/Medicaid
Not insured
8.
Child's Medicaid ID Number
9.
What is your reason for contacting tiny-k and what concerns do you or your referral have?
*
10.
Parent 1 Name
*
First
Last
11.
Parent 1 Relationship to Child
*
Parent 1 Relationship to Child
*
Mother
Father
Other, please specify
12.
Parent 1 Address
*
Street
City
State
Zip Code
13.
Parent 1 Phone
14.
Parent 1 Email
15.
Best Way to Contact
*
Best Way to Contact
*
Phone
E-mail
Other, please specify
16.
Parent 2 Name
First
Last
17.
Parent 2 Relationship to Child
Parent 2 Relationship to Child
Mother
Father
Other, please specify
18.
Parent 2 Address
Street
City
State
Zip Code
19.
Parent 2 Phone
20.
Preferred Language
*
Preferred Language
*
English
Spanish
Other, please specify
21.
How did you hear about tiny-k Early Intervention of Douglas County?
Family/Friend
Healthcare Provider
Childcare Provider
Advertisement
Other, please specify
22.
Referral's Name & Phone Number
23.
Child's Primary Care Physician
*
24.
Child's Childcare
25.
What time would work best for a visit in your home or childcare setting?
*
We cannot guarantee this time preference, but we do our best to work within families routines and the child's natural environment.
26.
Has your child had a vision screening?
*
Has your child had a vision screening?
*
Yes
No
27.
Any vision concerns?
*
28.
Did the child pass their newborn hearing screening?
*
Did the child pass their newborn hearing screening?
*
Yes
No
29.
Has your child had a hearing screening since birth?
*
Has your child had a hearing screening since birth?
*
Yes
No
30.
Any hearing concerns?
*
31.
Any nutrition concerns?
*