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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.
Your First Name:
Your Last Name:
Your Phone Number:
Your Email Address:
Child's ZIP Code:
How old is your child/children?
What services are you seeking for your child?
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
Preferred Language (if other than English):
Spanish
Haitian Creole
Russian
Cantonese
Mandarin
Bengali
Urdu
How did you hear about this service?
NYC Health Department Website
Community Event
Social Media
Word of Mouth
Early Intervention program
Other
