Kids On The Move

1. Child's Name*
2. Gender*
3. Child's Birth Date*
4. Was child born premature?
5. Yes No
6. If yes, how many weeks gestation?
7. Mother/Guardian*
8. Father/Guardian
9. Employed?
10. Yes No
11. If yes, where?
12. Address Where Child Resides*
13. City*
14. Zip Code / Postal Code*
15. Phone Number*
16. Family Email Address*
17. Is this child in foster care?
18. Yes No
19. Ethnicity Hispanic or Latino Not Hispanic or Latino
20. Race White American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander Other
21. What is the family's primary language?
22. Name of child's primary doctor
23. How did you hear about KOTM?
24. I'm concerned about my child's...
25. Communication Skills
26. Ability to talk How well my child understands others Understanding what my child says Other
27. Motor Skills
28. Gross motor skills (crawl, sit, walk, jump etc.) Eye-hand coordination Other
29. General Health
30. Hearing Vision Eating ability or habits Sleeping habits Prematurity (list in Other number of weeks) Other
31. Social Skills
32. My child seems overly withdrawn or shy Behavior with other children Lack of self control Activity level: seems to be too active or not ative enough Attention span My child has difficulty following directions Other
33. Medical Diagnosis/Syndrome
34. Has your child been diagnosed with a specific medical diagnosis or syndrome? (Example: Down Syndrome, Cerebral Palsy, Autism, Attention Deficit Disorder, etc.)
35. No Yes
36. If yes, please name or describe:
37. Do you have a medical report from your doctor that states the diagnosis or describes the syndrome?
38. Yes No
39. Do you have any additional concerns or is there anything else you would like us to know about your child?
40. Send me a copy

 

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Qualification Requirements

To qualify for Early Intervention services through Kids On The Move, you must:

• reside in the Alpine School District(Orem, Vineyard, Lindon, Pleasant Grove, American Fork, Highland, Cedar Hills, Alpine, Lehi, Saratoga Springs, Eagle Mountain, some parts of Draper)
• your child must be under 36 months of age

Make a Referral

Make a referral to Kids On The Move if you are concerned that your child is not reaching developmental milestones in the following areas:

• cognitive development
• physical development (including vision and hearing)
• communication development (speech, language)
• social or emotional development
• adaptive development
• or if your child has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay

EI Referral Form

You should be contacted by Kids On The Move in FIVE working days. If you have not been contacted in that time, please call us at 801.221.9930.