Referral Form/Application - Community Intervener Program

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Welcome to the CIP! We are excited to have you. Please fill in the information below and we'll get back to you ASAP with next steps.

Name *

Age *

School Grade, if applicable

Date of Birth *

YYYY

Gender *

Primary diagnosis *

Additional diagnoses, if applicable

Does the child/young adult have a school intervener? *

Yes

Other 1:1 support provider (e.g. signing para)

N/A or child is not in school

Does the child/young adult receive SSP services? *

Yes

Is the child/young adult registered with the Colorado Deaf-Blind Project? *

Yes

Other:

Does the child/young adult have coverage through one or more of the following programs? *

Colorado Medicaid

CHCBS

CES

CLLI

Buy-In

Income-Based Medicaid

SLS

EBD

None of the Above

Other:

Required

Do you have a specific intervener in mind for the child/young adult? (Anyone in their life who would like to go through the intervener training in order to work with them through the program, excluding therapists or family members) *

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