Anyone can refer a child to ECI In most cases a child is referred by his or her parents or by the child’s health care provider. Anyone can make a referral, a parent, grandparent, doctor, nurse, friend, social worker, etc. To refer a child simply fill out the form below and click submit. LifePath Systems serves Collin, Kaufman, Grayson, Fannin and Rockwall counties.Todays Date MM slash DD slash YYYY CHILD'S INFORMATIONName:(Required) First Last DOB:(Required) MM slash DD slash YYYY Sex:(Required) M F Hispanic or Latino?:(Required) Yes No Race:(Required) White Black Asian American Indian/Alaska Native Hawaiian/Pacific Islander Reason for Referral/Concerns:(Required) Physical/Motor Speech/Language Vision/Hearing Global Adaptive/Self Help Cognitive Premature: Yes No How many weeks?: Birth Weight: Pediatrician: Last Well Visit: Other Doctors: Diagnosis: Recent Health: Good Of Concern State Concern: Comments:Your Name:(Required) Agency:(Required) Agency Type:(Required)Select OneECI ProgramParent/Family/FriendMedical/HealthSocial ServicesOtherPhone:(Required)Your Email:(Required) FAMILY INFORMATIONCaregiver #1:(Required) Caregiver #2:(Required) Street:(Required) City:(Required) Zip:(Required) County:(Required) ISD:(Required) Phone (preferred home contact number):(Required)Alternate Phone 1:Alternate Phone 2:Email(Required) Language Spoken in Home:(Required) INSURANCE INFORMATIONType: Insurance Medicaid Chip None Insurance Policy Holder D.O.B. Group # I.D. # Provider Tel # Medicaid/Chip # Current Plan Effective Date CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
