30.F16 Sample Form Letter Text (pdf)
This text may be individualized for each child and family.
(Child's name) was recently referred to Child and Family Connections by (referral source) because of concerns with his/her (adaptive/cognitive/communication/motor/ social-emotional development. Child and Family Connections is the regional system point
of entry for the state's Early Intervention Services System. Early Intervention provides services and supports to infants and toddlers with developmental concerns and their families. Participation is voluntary.
I have not been able to contact you by phone and have received no response to our first letter dated (date of first letter). Please contact me in the next two weeks to let me know if you are interested in moving forward with this referral. I can be
reached at (service coordinator phone number), or you can return this letter in the enclosed envelope. I look forward to hearing from you.
If I do not hear from you by (10 days), I will assume you do not wish proceed with the referral at this time. If at any time before your child turns three you wish to learn more about Early Intervention, please feel free to contact us.
- Informational Brochure(s)
- Rights Booklet
Check one and return in the enclosed envelope if unable to contact me by phone:
- Please call me at this number: ______________, at this time: ______________ to discuss this further.
- I am not interested at this time.