Refer A Child - UO Early Childhood CARES

Parents, child care providers, physicians, educators and anyone else concerned about development should complete an Ages and Stages Questionnaire and use the results to engage in conversation with families before proceeding with referral. You should never refer a child without family consent.

NOTE: If your form submission fails or you get an hCAPTCHA verification failed notice, please scroll down to the bottom of the form and click the “I’m not a robot” checkbox, as this helps us prevent form misuse and spam.

Your First and Last Name *

Parent/Guardian First and Last Name *

Relationship to Child

Your Contact Number *

Parent/Guardian Contact Number *

Your Email *

Parent/Guardian Email *

Child's First and Last Name *

Childs Birth Date *

MARK ALL AREAS OF CONCERN *

Cognitive - thinking, reasoning, problem solving, playing
Adaptive - eating, dressing, toileting, self care
Social/Emotional - interactions with peers and adults
Fine Motor - use of hands and fingers
Gross Motor - sitting, crawling, walking, running, climbing
Receptive Communication - following directions, understanding what is said
Expressive Communication - using words/sounds/gestures, how words are pronounced

TELL US ABOUT THE CHILD. WHAT ARE YOUR MAIN CONCERNS? *

Once you submit you will be redirected to fill out the Ages and Stages Questionnaire website. Please take a moment to fill out the appropriate questionnaire or bookmark the page for a more convenient time in the near future. We will be in touch soon.