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- CPSE (3-5) Evaluation Referral Form
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EI Provider Assistance For Ages 0-3 Years

Your child has been approved for services. That's great! Now you need a provider. Omni Childhood Center will do our best to assist you. Fill in the form below and upload your child's IEP.

OMNI Childhood Center

EI Provider Assistance Form

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

EI Provider Assistance Form 0-3 Years

Child Last Name, MI, First Name

Cell

Child Last Name, Child First Name, MI

Child's Date of Birth * required

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 a contact person at school?

Which agency did your evals?

Which services is your child mandated to receive?

ABA/Special Instruction

Speech Therapy

Occupational Therapy

Physical Therapy

Hours of service per week, per service?

Which mandated service has your child not been receiving?

ABA/Special Instruction

Speech Therapy

Occupational Therapy

Physical Therapy

Who is your service coordinator?

Your service coordinator's contact number and email address:

Questions, concerns or additional information:

IFSP/documents received at your meeting:

Upload your child's IFSP

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 provides Early Intervention (0–3), CPSE evaluations (3–5), and SEIT services across New York City, including Brooklyn, Queens, Manhattan, Staten Island, and the Bronx.

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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