Early Intervention Reporting Form

It is important that all service providers adhere to New York State Early Intervention Regulations and County Department of Health Early Intervention protocols to ensure that services your child is entitled to are being delivered as authorized in your Individualized Family Service Plan; in accordance with federal, state and local laws. By reporting your concerns you help us improve the quality of the Early Intervention Program.

Information to be completed by the reporter.

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Please enter your ten digit phone number
Please enter your ten digit phone number
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Although the above information is not required, having your contact information will expedite the investigation if we should need additional information. Your contact information will always be kept confidential.

Where you see an asterisk below, that information is required.

What is the name of the person you are reporting?*

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Enter the verification code in order to submit the form.
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