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- CPSE (3-5) Evaluation Referral Form
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Child with a book Peeking Omni Childhood Center

CPSE Provider Assistance For Ages 3-5 Years

You have gone through the process of getting your child evaluated, and your child has been approved for services. However, you need help finding a provider to work with your child's schedule/school.

Omni Childhood Center will do our best to find the right provider for you child.

Let's begin.

OMNI Childhood Center

CPSE Provider Assistance Form

Fill out the CPSE provider assistance form below to get started.

CPSE Provider Assistance Form

Guardian Last Name, First Name

Cell

Child Last Name, MI, First Name

Child Date of Birth

Street Address

City, State, Zipcode

Does your child attend a daycare or preschool?

Yes

What is the school name, address and phone number ?

What is the name and phone number of the contact person at school?

Which agency did your CPSE evals?

Which services is your child mandated to receive?

SEIT-Special Education

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling

Behavioral/Helath Para

Hours of service per week, per service?

Which mandated service has your child not been receiving?

SEIT-Special Education

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling

Behavioral/Health Para

Questions, concerns or additional information:

IEP/documents received at your meeting:

Upload your child's IEP

I agree to share the above information with Omni Childhood Center and its representatives.

Thank you for submitting!

Star

We'd love to hear from you!
Your feedback is important to us.

Omni Childhood Center

1651 Coney Island Avenue Brooklyn, New York 11230

Tel: 718.998.1415 • Fax: 347.544.2888

info@omnichildhoodcenter.com

Confidentiality Notice: The information submitted here may contain confidential and privileged information for the use of the designated recipients review, disclosure, dissemination, distribution or copying of it or its contents is prohibited.

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