Infant & Toddler Connection Referral Form

Welcome to the Infant & Toddler Connection Harrisonburg-Rockingham (ITC). We provide early intervention services for infants and toddlers under the age of three years who have a developmental delay, atypical development or a diagnosis which commonly causes developmental delays. Our program serves families residing in Harrisonburg City and Rockingham County by providing Speech Therapy, Developmental Services, Occupational Therapy, Physical Therapy, Service Coordination, and Behavior Services. We believe parents and caregivers are the first and most important teachers for their children, which is why early intervention services are delivered in the home or natural environment rather than a clinic setting. Anyone can make a referral if they are concerned with any aspect of a child’s development. The ITC program will schedule a FREE developmental screening at your home to help determine if services are needed.

Referral Information

Your First Name (Required)*

Your Middle Name

Your Last Name (Required)*

Your Email Address

Your Telephone Number (Required)*

Please select the source of this referral (Required)*

If other referral source, please specify

Child Information

Child's First Name (Required)*

Child's Middle Name

Child's Last Name (Required)*

Child's Date of Birth (Required)*

Child's Gender

Female
Male

Child's Race

Street Address Line #1 (where the child resides)

Street Address Line #2

City

State

Zip Code

Jurisdiction (Required)*

Harrisonburg
Rockingham County
I don't know

Parent/Guardian Information

COPY FROM REFERRAL'S INFORMATION

Parent/Guardian's First Name (Required)*

Parent/Guardian's Middle Name

Parent/Guardian's Last Name (Required)*

Parent/Guardian's E-mail Address

Parent/Guardian's Telephone Number (Required)*

Relationship to Child (Required)*

Mother
Father
Guardian
Other

If other relationship to child, please specify

Further Information

Please enter your primary concern for the child (ex. Late Talking, Late Walking, Speech, Physical Therapy, Nutrition, Feeding)

Please enter the language(s) spoken in the home (ex. English, Spanish, Korean) (Required)*

Please check if interpretation is required

Yes- Interpretation will be needed
No- Interpretation will not be needed

Attach any relevant files here

Max. file size: 512 MB.

Phone

This field is for validation purposes and should be left unchanged.

Referral Information

Child Information

Parent/Guardian Information

Further Information

QUICK LINKS

Harrisonburg-Rockingham
Community Services Board

Referral Information

Child Information

Parent/Guardian Information

Further Information

QUICK LINKS

Harrisonburg-Rockingham Community Services Board

Harrisonburg-Rockingham
Community Services Board