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 Race
*
mark all applicable if 2 or more
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
5.
Child's Ethnicity
*
Child's Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
6.
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
7.
Child's Medicaid ID Number
8.
What is your reason for contacting tiny-k? What concerns do you or your referral have? What behaviors are you seeing with your child and in what areas are you needing support?
*
9.
Contact Name
*
First
Last
10.
Relationship to Child
*
Relationship to Child
*
Mother
Father
Other, please specify
11.
Address
*
Street
City
State
Zip Code
12.
Phone
13.
E-mail
14.
Best Way to Contact
*
Best Way to Contact
*
Phone
E-mail
Other, please specify
15.
Preferred Language
*
Preferred Language
*
English
Spanish
Other, please specify
16.
How did you hear about tiny-k Early Intervention of Douglas County?
*
Family/Friend
Healthcare Provider
Childcare Provider
Advertisement
Other, please specify
17.
Referral's Name & Phone Number
18.
Child's Primary Care Physician
*
19.
Child's Childcare
20.
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.
21.
Has your child had a vision screening?
*
Has your child had a vision screening?
*
Yes
No
22.
Any vision concerns?
*
23.
Did the child pass their newborn hearing screening?
*
Did the child pass their newborn hearing screening?
*
Yes
No
24.
Has your child had a hearing screening since birth?
*
Has your child had a hearing screening since birth?
*
Yes
No
25.
Any hearing concerns?
*
26.
Any nutrition concerns?
*