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Responderemos a cada remisión en un plazo de dos días laborables.
Tenga en cuenta que la información se enviará a A Shared Vision a través de un servicio no cifrado que no cumple con la HIPAA.
Formulario de remisión en línea
Información del niño
*
Indicates required field
Nombre del niño
*
Edad del niño
*
Persona que remite al niño
Nombre de la persona que remite al niño
*
First
Last
Organización (opcional)
*
Número de teléfono de la persona que remite al niño
*
Correo electrónico de la persona que remite al niño
*
Información sobre el cuidador
Nombre del cuidador (principal)
*
First
Last
[object Object]
Dirección del cuidador (principal)
*
Line 1
Line 2
City
State
Zip Code
Country
Número de teléfono del cuidador
*
Correo electrónico del cuidador
*
Otros datos
¿Recibe el niño servicios de intervención temprana?
*
Sí
No
Desconocido
En caso afirmativo, nombre del CCB/agencia
*
Notas
*
"Al enviar este formulario de remisión, reconozco que entiendo que la información proporcionada anteriormente será sin cifrar y enviada por correo electrónico a referrals@ASharedVision en un formato que no cumple con la ley HIPAA. Tengo la opción de solicitar una devolución de llamada para una conversación confidencial."
Enviar
Home
Refer a Child
Refer a Child
Frequently Asked Questions
Stay Informed
Latest News
Newsletters
Annual & Financial Reports
Parent Resources
Parent Resources Introduction
Let's Play!
Learning Experiences©
>
Learning Experiences©
Expanded Core Curriculum
Sensory Recipes
>
Sensory Recipes Introduction
Sensory Recipes
Gift Ideas
Digital Resources
>
Overview
Building Communication Skills
CVI
Dual Sensory Loss
Early Emergent Literacy
Feeding
Eye Conditions
Eye Glasses for Your Child
Meeting with Your Ophthalmologist
Orientation & Mobility
Routines
Sleep
Strategies
Tactile Skills
Transition to Preschool
Other Great Organizations
For Our Families
Welcome New Families
Top digital resources for new families
Inspiring Families
Esmeralda's Day
Vision Screening
Importance of Vision Screening
Protocol & Resources
Vision Screening Training
Directory Pediatric Eye Doctors
For EI Evaluators
Donate Now
Donate Now
Value of Early Intervention
CO Child Care Tax Credit
Trainings & Education
About Us
Our Mission, Goal, Values
What We Do
Our Team
Our Partners