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Early Stages Referral Form

Early Stages Referral Form

Anyone can refer a child for a developmental screening or evaluation. Early Stages needs consent from the parent before beginning an evaluation. It is important to refer if you have any questions about how a child is playing, learning, or developing. If you are missing any information in a required field, please write/ type in "unknown."

To refer a child to Early Stages:

Download the referral form in Spanish, Amharic, Vietnamese, French, and Mandarin below. 

Early Stages can only screen and evaluate children aged 2 years 8 months to 5 years 10 months. For older children enrolled in DCPS or charter schools, contact the child’s school. For older children enrolled in private or religious schools, refer to the DCPS Central IEP Team. For children under 2 years 8 months, refer to Strong Start DC. If you have any questions about where to refer, call or email Early Stages.


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Child Information (* Indicates a required field.)
(First Name)
(Last Name)
Date of Birth, please enter format 01/01/2010 or 01-01-2010
Check any that apply.
Check one.
(First Name, Last Name)
Please enter the phone number in this format 202-555-5555
Please enter the phone number in this format 202-555-5555
Check any that apply.
Referrer Information (Only complete if you are not the parent.)
(First Name, Last Name)
Please enter the phone number in this format 202-555-5555
Please enter the phone number in this format 202-555-5555
Medical Provider Information (This information helps us serve the family, but it is not required to make a referral.)
(First Name, Last Name)
Please enter the phone number in this format 202-555-5555
Social Worker Information (This information helps us serve the family, but it is not required to make a referral.)