07/30/14
Informational Notice
To: All Medical Assistance Providers
Re: Standardized Referral Form for Early Intervention
Objective Developmental Screening
Referrals
When a child, three years of age or younger, needs a comprehensive evaluation for suspected developmental delay, a referral to the Department of Human Services’ (DHS) Early Intervention (EI) program, Child and Family Connections (CFC) offices can be made using the “Standardized Illinois Early Intervention Referral Form” Form 650, available on HFS’ Medical Program Forms webpage. Search either alphabetically or by form number. The form can be printed or saved to your computer for use. The form includes a hyperlink to an online tool to look up the CFC office(s) serving your area. A list of CFC offices by the counties they serve is attached to this Notice for reference.
The advantages of using the standardized referral form are:
- The form secures consent that meets Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) requirements;
- The form initiates a process whereby EI CFC office staff send information back to the referring provider about the outcome of the referral; and
- The referral form is sent from the provider directly to the local EI CFC office thereby removing the burden on the family to contact EI.
The referral form is paired with a standardized “Illinois Early Intervention Program Referral Fax Back Form” Form 652 (available on the Medical Program Forms webpage) to assure that the referring provider, with proper consent secured using the referral form, receives information about the outcome of the referral. EI CFC staff complete Part 1 of 2 after they contact the family to inform the referring provider about the outcome of the contact. When EI CFC staff cannot reach the family, providers should follow-up with the family to encourage them to contact their local EI office. Part 2 of 2 is completed by EI CFC staff after the child receives an assessment to inform the provider about the outcome.
Currently, these forms are faxed between the provider and the local EI CFC office. In development is an online referral system whereby providers may send referral information electronically to the local EI CFC office. The referring provider will be notified via e-mail that outcome information is available. Information about this developing process will be shared at a later date.
The forms and communication processes were tested through a pilot project conducted by HFS, DHS and the Illinois Chapter, American Academy of Pediatrics (ICAAP). The project was funded by The Commonwealth Fund and administered by the National Academy for State Health Policy.
Providers wishing to receive e-mail notification when new provider information is posted by the Department may register on the HFS Provider Releases and Bulletins E-mail Notification Request webpage.
Theresa A. Eagleson, Administrator
Division of Medical Programs
Child and Family Connections Listing of Illinois
Illinois Department of Human Services- Bureau of Early Intervention Early Intervention
Revised – June 2014
Illinois Department of Human Services- Bureau of Early Intervention Early Intervention
Revised – June 2014
| CFC | CFC Site Address, Phone, Fax & Toll Free Numbers | Serving County(s) and/or Zip Codes |
|---|---|---|
| 1 | Child & Family Connections Access Services of Northern Illinois 1752 Windsor Rd., Ste. 102/ PO Box 16390 Loves Park, IL 61132-6390 815-654-6170 Fax: 815-654-6197 Toll Free #: 800-921-0094 |
Boone Bureau Marshall Ogle Putnam Winnebago |
| 2 | Child & Family Connections Lake County Health Department 3010 Grand Ave., 2nd Floor Waukegan, IL 60085 847-377-8900 Fax: 847-377-8939 Toll Free #: 888-539-3033 |
Lake |
| 3 | Child & Family Connections Regional Office of Education for Carroll, Jo Daviess, & Stephenson Co. 27 S. State Avenue, Suite 101 Freeport, IL 61032-4210 815-297-1041 Fax: 815-297-9032 Toll Free #: 888-297-1041 |
Carroll DeKalb Jo Daviess Lee Stephenson Whiteside |
| 4 | Child & Family Connections DayOne Network 1551 E. Fabyan Pkwy. Geneva, IL 60134 630-879-2277 Fax: 630-761-9810 Toll Free #: 888-282-0997 |
Kane Kendall |
| 5 | Child & Family Connections PACT, Inc. 750 Warrenville Rd., Suite 300 Lisle, IL 60532 630-493-0400 Fax: 630-493-1995 Toll Free #: 800-637-7181 |
DuPage County including the following Cook County zip codes: 60103 and 60126 |
| 6 | Child & Family Connections Clearbrook Center 1835 W. Central Rd. Arlington Heights, IL 60005 847-385-5070 Fax: 847-385-7260 Toll Free #: 800-585-1953 |
*Cook County North Suburban including the following zip codes: 60004 60005 60006 60007 60008 60010 60015 60016 60018 60022 60025 60026 60029 60035 60043 60053 60056 60062 60067 60068 60070 60074 60076 60077 60082 60089 60090 60091 60093 60095 60106 60107 60120 60133 60143 60149 60157 60169 60172 60173 60192 60193 60194 60195 60196 60201 60202 60203 60204 60666 60712 60714 |
| 7 | Child & Family Connections Suburban Access, Inc One Westbrook Corporate Center, Suite 640 Westchester, IL 60154 708-449-0625 Fax: 708-449-7071 Toll Free #: 888-566-8228 |
*Cook County Central Suburban including the following zip codes: 60104 60130 60131 60141 60153 60154 60155 60160 60162 60163 60164 60165 60171 60176 60301 60302 60303 60304 60305 60402 60513 60521 60525 60526 60527 60534 60546 60558 60706 60707 60804 |
| 8 | Child & Family Connections Easter Seals Society of Metropolitan Chicago 9455 S. Hoyne Ave. Chicago, IL 60643 773-233-1799 Fax: 773-233-2011 239-6229 Toll Free #: 866-266-7167 |
*Cook County Chicago Southwest including the following zip codes: 60620 60628 60629 60633 60638 60643 60652 60655 60805 60827 *This CFC serve those families who reside within the City of Chicago when the zip codes cross the city lines. |
| 9 | Child & Family Connections Fantus Health Center 1901 W. Harrison St., Rm. A2101 Chicago, IL 60612 312-864-6575 Fax: 312-864-9332 Toll Free #: 888-816-3188 |
*Cook County Chicago Central/ West including the following zip codes: 60601 60602 60603 60604 60605 60606 60607 60608 60612 60616 60623 60624 60632 60644 60661 |
| 10 | Child & Family Connections La Rabida Children’s Hospital 1525 E. 55th St., Suite 203 Chicago, IL 60615 773-324-7434 Fax: 773-324-7469 Toll Free #: 800-862-1912 |
*Cook County Chicago Southeast including the following zip codes: 60609 60615 60617 60619 60621 60636 60637 60649 60653 |
| 11 | Child & Family Connections 945 W. George St., Suite 300 Chicago, IL 60657 312-942-7800 Fax: 312-942-7811 Toll Free #: 800-289-7990 |
*Cook County Chicago North including the following zip codes: 60610 60611 60613 60614 60618 60622 60625 60626 60630 60631 60634 60639 66040 60641 60642 60645 60646 60647 60651 60654 60656 60657 60659 60660 |
| 12 | Child & Family Connections Easter Seals Society of Metropolitan Chicago 17300 S. Ozark Ave. - North Bldg. Tinley Park, IL 60477 708-429-8231 Fax: 708-429-8246 Toll Free #: 800-597-7798 |
*Cook County South Suburban including the following zip codes: 60406 60409 60411 60415 60417 60419 60422 60423 60425 60426 60428 60429 60430 60439 60438 60443 60445 60448 60449 60452 60453 60455 60456 60457 60458 60459 60461 60462 60463 60464 60465 60466 60467 60469 60471 60472 60473 60475 60476 60477 60478 60480 60482 60487 60491 60501 60803 |
| 13 | Child & Family Connections Reg. Office of Education # 26 1301 N. Main St., Suite 3 Monmouth, IL 61462 309-734-3336 Fax: 309-734-1145 Toll Free #: 866-426-2160 |
Fulton Hancock Henderson Knox McDonough Mercer Rock Island Schuyler Warren |
| 14 | Child & Family Connections 3000 W. Rohmann Ave. West Peoria, IL 61604 309-672-6360 Fax: 309-681-0190 Toll Free #: 888-482-4300 |
Henry Peoria Stark Tazewell Woodford |
| 15 | Child & Family Connections Services of Will, Grundy, & Kankakee Counties, Inc. 2300 Glenwood Ave. Joliet, IL 60435 815-730-2617 Fax: 815-730-2650 Toll Free #: 888-329-0633 |
Grundy Kankakee LaSalle Will |
| 16 | Child & Family Connections 103 S. Country Fair Dr. Champaign, IL 61821 217-693-7958 Fax: 217-693-7967 Toll Free #: 800-877-1152 |
Champaign Ford Iroquois Livingston McLean Vermilion |
| 17 | Child & Family Connections ROE of Adams/Pike Counties 510 Maine St., Suite 615 Quincy, IL 62301 217-222-9592 Fax: 217-222-9593 Toll Free #: 888-222-9592 |
Adams Brown Calhoun Cass Greene Jersey Morgan Pike Scott |
| 18 | Child & Family Connections Sangamon Co. Public Health Department 2833 South Grand Ave., East Springfield, IL 62703 217-535-3100 Fax: 217-793-3991 Toll Free #: 888-217-3505 |
Logan Mason Menard Sangamon |
| 19 | Child & Family Connections Macon County Community Mental Health Board 132 S. Water St., Suite 604 Decatur, IL 62523 217-423-6199 Fax: 217-233-7028 Toll Free #: 800-758-2705 |
Clark Coles Cumberland DeWitt Douglas Edgar Macon Moultrie Piatt Shelby |
| 20 | Child & Family Connections ARC Community Support Systems 1901 S. 4th St., Suite 209 Effingham, IL. 62401 217-347-5601 Fax: 217-347-5119 Toll Free #: 888-459-5437 |
Bond Christian Clay Crawford Effingham Fayette Jasper Lawrence Macoupin Montgomery Richland |
| 21 | Child & Family Connections Regional Office of Education #13 4 Eagle Center, Suite 4 O’Fallon, IL 62269 618-622-6581 Fax: 618-622-8662 Toll Free #: 888-594-8364 |
Madison Monroe Randolph St. Clair |
| 22 | Child & Family Connections Regional Office of Education #13 101 S. Lincoln Blvd. Centralia, IL 62801 618-532-4919 Fax: 618-532-0856 Toll Free #: 800-661-0900 |
Clinton Franklin Jefferson Marion Washington Williamson |
| 23 | Child & Family Connections Wabash & Ohio Valley Special Education Dist. 800 S. Division St./PO Box 320 Norris City, IL 62869 618-378-2131 Fax: 618-378-3127 Toll Free #: 800-463-2759 |
Edwards Gallatin Hamilton Saline Wabash Wayne White |
| 24 | Child & Family Connections Archway, Inc. 2751 W. Main St./ PO Box 1180 Carbondale, IL 62901-1180 618-529-3147 Fax: 618-549-8137 Toll Free #: 888-340-6702 |
Alexander Hardin Jackson Johnson Massac Perry Pope Pulaski Union |
| 25 | Child & Family Connections Options & Advocacy for McHenry Co. 365 Millennium Dr., Suite A Crystal Lake, IL 60012 815-477-4720 Fax/TDD: 815-788-0704 Toll Free #: 888-376-8828 |
McHenry |
Special Notes:
* When a zip code crosses county lines, Cook Child and Family Connections will serve the portion that falls within Cook County.
** Toll free numbers are only accessible within Illinois. All other states must use the local number listed.
*** CFCs that are Satellite Offices- CFC 27 reports to CFC 17, CFC 28 reports to CFC 14 & CFC 29 reports to CFC 1
If you have any questions or have changes regarding this listing, please contact the DHS, Bureau of Early Intervention at 217-782-1981.
If you would like more information on Early Intervention, please visit the DHS for Early Intervention Providers webpage and review the brochures and manuals sections.
