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Early Stages Referral Form

A referral will begin a child’s process with Early Stages. It is easy to refer a child to Early Stages, you may:

  • Call us at (202) 698-8037
  • Send an email to [email protected]
  • Refer your child online below

You can also download and fax a referral form[PDF] to us at (202) 654-6079.

Anyone may refer a child to Early Stages, but we will not move forward without the parent or guardian’s consent. If you would like to share information about Early Stages with others, please feel free to download and share our outreach postcard[PDF].

The Office of the State Superintendent of Education (OSSE) identifies infants from birth to 3 years of age through their early intervention program Strong Start. If you have a concern about a child younger than 2 years, 8 months, call (202) 727-3665 or email [email protected] to make a referral.

Child Information
(First Name, Last Name)
Format: mm/dd/yyyy
Check any that apply
Check one
Check any that apply
(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
Referrer Information (please complete if you are not the parent of the child being referred).
(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
Additional Information (please complete if known).
(First Name, Last Name)
Please enter the phone number in this format 202-555-5555
(First Name, Last Name)