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Referral Form

Disclosure *

By using the website, you agree that Exceptional Parents Unlimited is authorized to use the information presented for the sole purpose of referral to services provided by programs within the agency that will address the needs described regarding yourself or your child.

Every effort will be made to keep the information you provide confidential. This consent pertains only to information collected through our website.

You must agree before you can complete the form.



Referral *

Adult Information

Child Information

Referral Information

Reasons for referral (check all that apply):
Assessment of children to age 6 for whom there are concerns with development, speech, learning, and services have not been accessed elsewhere. Limited behavioral assessment and/or referral services to age 10.
Parent Support Birth to 3 years of age: Parent to Parent support including phone support, face to face support and parent groups facilitated by experienced parents. Training and Clinics related to the IFSP process. Resource information, coordination and referral services. Parent Support/Advocacy 3 years of age and older: Parent to Parent support including phone support, face to face support and parent groups facilitated by experienced parents. Training and Clinics related to the IEP process. Training in a variety of topics to increase knowledge and advocacy skills.
Infant Family Program/Early Intervention serves infants from birth to 3 years of age whose development is delayed. Children participating in this program must qualify through Central Valley Regional Center. Gentle Start/High Risk Serves infants from birth to 3 years of age whose development seems to be falling behind. Children participating in this program do not meet eligibility qualifications for Early Start services through Central Valley Regional Center and live within Fresno County.
Home Visitation: Home based parent education, support and advocacy for parents/caregivers of children 0-5 years old Parent Education: Variety of parent education classes and center based support for parents/caregivers of children 0-5 years old