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Children and Youth with Special Health Care Needs Program Online Referral Form
Please complete this form and NYC Health Department staff will follow up with you soon.
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Your First Name:
(Required.)
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Your Last Name:
(Required.)
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Your Phone Number:
(Required.)
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Your Email Address:
(Required.)
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Child's ZIP Code:
(Required.)
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How old is your child/children?
(Required.)
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What services are you seeking for your child?
(Required.)
Evaluation information
Therapy information
Summer Camps, Recreation, or After School information
Respite Services information
Committee on Preschool Special Education (CPSE)/Committee on Special Education (CSE) information
Early Intervention referral
General information
Housing or Food Assistance information
Parent and Family Support information
Mental Health Resources information
Health Insurance referral
Other
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Preferred Language (if other than English):
(Required.)
Spanish
Haitian Creole
Russian
Cantonese
Mandarin
Bengali
Urdu
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How did you hear about this service?
(Required.)
NYC Health Department Website
Community Event
Social Media
Word of Mouth
Early Intervention program
Other
