Refer A Family - UIC Division of Specialized Care for Children

Caregiver's Name*

Who should we contact?

Child's Name*

What is the child's name?

Child's Date of Birth

Caregiver's Phone Number*

What phone number should we use to contact the family?

Caregiver's Email Address*

What email address should we use to contact the family?

Caregiver's Street Address*

If we can't reach the family by phone/email, we will mail them general information about our program.

City*

State*

Please note we can only serve Illinois residents.

Zip Code*

The family's zip code tells us which regional office will help them.

County

The family's county tells us which regional office will help them.

Family's Primary Language

What is the family's preferred language?

Child's Diagnosis

Please describe the child's medical condition.

Has the child previously been enrolled with the Division of Specialized Care for Children?*

What services does this family need?

What type of insurance does the family have?

Are you referring yourself?*

Your Name*

Your Phone Number*

Your Email Address*

Is the family aware of this referral?*

Please share any other details that would be helpful for our team to know:

This gives us a little understanding before we contact them.

Comments

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