Referral Form

Nondiscrimination Clause/Title IX

It is the policy of the Berrien Regional Education Service Agency not to discriminate in its policies and practices with respect to compensation, terms, or conditions of employment because of an individual's race, color, religion, sex, national origin, height, weight, marital status, political belief, genetic information, disability or handicap which does not impair an individual's ability to perform adequately in that individual's particular position or activity.

Title IX Coordinator/Compliance Officer and for all other concerns:
Lynda Hurlow, Executive Director of Human Resources

Title IX Investigators: Kevin Clark, Technology Services Director and Lynda Hurlow, Executive Director of Human Resources

Title IX Decision Maker: Chris Machiniak, Assistant Superintendent

Title IX Appeals: Eric Hoppstock, Superintendent

Berrien RESA
711 St. Joseph Avenue
Berrien Springs, MI 49103

For procedural information, please review NEOLA Board Policy No. 2260

Please note that some pages on the Berrien RESA website contain links to third-party sites (including social media platforms). Berrien RESA is not responsible for the online content or accessibility of third-party sites, which do not relate to Berrien RESA programs, services and activities.

Early On® is the system of early intervention services for infants and toddlers, birth to three years of age, with disabilities or delays, and their families. The information that you provided will be kept completely confidential. Within 10 calendar days, the family will be contacted by a local Early On staff member from the local school district.
How did you find out about us?	Physician/Pediatrician Hospital Child Protective Services Teacher/Education Professional Childcare Provider Family Member Web Site Advertisement Other
Child's Information
First Name
Middle Name
Last Name
Date of Birth
Gender	Male Female
Ethnicity	Please select one of the following or select "Unknown/Unsure"
Was the child premature?	Yes No Unsure
Is the Child a twin/triplet?	Yes No
Has the child had an IFSP?	Yes No Unsure
Speech or language concerns?	None Speech: articulation/pronunciation Language: the number of words Both
Description of concern:
Parent/Guardian Information
Guardianship	Birth Parent Adoptive Parent Foster Parent Legal Guardian Other
Parent First Name:
Parent Last Name:
Email:
Home Phone:
Alternate Phone:
What's the best time to call?
Street Address:
City:
State:
Zip Code:
School District:
Internet Connection?	Unsure Yes No
Your Contact Information
Your relation to the child:	Parent/Legal Guardian Grandparent Sibling Aunt/Uncle Family Friend Neighbor Physician Teacher/Educator Childcare Provider Other
Your First Name:
Your Last Name:
Phone:
Fax:
Address:
City:
State:
Zip:
Your Email:
Is the family aware of your referral?	Yes No
Is it OK to contact the family regarding your referral?	Yes No
Would you like to receive status of family's placement?	Yes No
If yes, who would you like us to contact?
Physician Information Name: Name of Practice: Date of Last Exam: Medical Diagnosis: ICD Code:

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Nondiscrimination Clause/Title IX