ECI Referral Form

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, and Rockwall counties.

Todays Date:

CHILD'S INFORMATION
DOB:*
Name:*
Hispanic or Latino?*
Sex:*
Race:*
Reason for Referral/Concerns:*
Premature:
How many weeks?:
Birth Weight:
Last Well Visit:
Pediatrician:
Other Doctors:
Diagnosis:
Recent Health:
State Concern:
Comments:
Your Name*
Agency:*
Phone:*
Agency Type:*
Your Email:*
FAMILY INFORMATION
Caregiver #2:*
Caregiver #1:*
Street:*
City:*
Zip:*
ISD:*
County:*
Phone (preferred home contact number):*
Alternate Phone 1:
Alternate Phone 2:
Language Spoken in Home:*
E-mail:*
INSURANCE INFORMATION
Type:
Insurance
Policy Holder
D.O.B.
Group #
I.D. #
Provider Tel #
Medicaid/Chip #
Current Plan
Effective Date