top of page

DONATE/BECOME A SPONSOR

Home
About Us
Programs
Resources
How Can I Help?
Contact Us
- Referral
More

Use tab to navigate through the menu items.

Information/Referral for Services

Main Phone Number: 815-477-4720

Helping Us Grow (HUG) Prevention Initiative Program (Prenatal-3) - ext. 234
Child and Family Connections (CFC) #25 (Birth-3) - ext. 238
Autism Resource Center (ARC) (ASD or suspects ASD)- ext. 225
Neuro Inclusive Counseling (NIC)- ext. 403

GENERAL REFERRAL FORM

The below information is for the person being referred

First Name

Preferred Name

Address (include town)

Middle Name

Last name

Date of Birth:

Age:

Primary language:

Gender

Male

Female

Unknown

Non-binary

Name/Agency/Phone of who referred:

Referred to:

CFC

HUG

ARC

NIC

Insurance type:

Private

All Kids/Medicaid

None

Please check all that apply

SNAP

TANF

WIC

CCAP

Reason for referral (concerns about development? Family stressors? Autism Spectrum Disorder or suspected ASD)

Primary Contact/Name

Relationship

Cell

Email

Preferred Language

DOB

Secondary Contact/Name

Relationship

Preferred Lang

DOB

Cell

Email

If the person being referred is 3 yrs. old or under, please complete all questions in the below gray box.

Gestation- 40 weeks if full term

Birth weight

Concerns with hearing?

History of ear infections? #

Race:

Child's living arrangement

# of immediate family in household:

Other children living in home (with DOB)

Has child or sibling been previously enrolled in EI:

Yes

No

Physician Name/Practice

Physician Phone

Physician Fax

Comments/Preferred method of contact (phone, email, text):

I agree to the terms & conditions

By providing information, you are attesting that either (1) you are your own guardian making a self-referral, (2) you are the youth's parent/guardian or (3) you have consent from the youth's parent/guardian to share this information. In any case, please be aware that the client and/or youth's parent/guardian will be contacted by an agency representative to obtain consent and in order to provide assistance in identifying appropriate services. If you do not provide the parent/guardian's contact information or if a parent/guardian cannot be reached to provide consent, the agency representative will not be able to follow up.

Thanks for submitting!
The program intake coordinator will be contacting you shortly.

© 2021 by Options & Advocacy for McHenry County

To view our privacy policies click here.

Call us:

815-477-4720
Fax:

815-477-4700

Find us:

365 Millennium Drive Suite A

Crystal Lake, IL 60012

Office Hours:

Monday - Thursday: 8:00 - 4:00

Friday: 8:30 - Noon

bottom of page