A
A
A
Lewis County
New York
Departments
Board of Elections
Board of Legislatures
Building & Fire Codes
Commissioner of Jurors
Community Services / L.G.U.
County Attorney
County Clerk
County Court
County Historian
County Manager
Buildings & Grounds Maintenance
Probation
District Attorney
Courts Services
Public Defender
Supreme Court
Surrogate Court
Economic Development
Emergency Management
Highway Department
Human Resources & Civil Service
Information Technology
Department of Motor Vehicles
Office for the Aging
Planning
Public Health
Adult Day Health Care
Cancer Services Program
Lewis County Hospital
Public Transportation
Recreation Forestry and Parks
Sheriff
Social Services
Solid Waste Department
Treasurer
Veterans Service Agency
Weights & Measures
Youth Bureau
COVID-19
GIS Maps
Forms
Building, Junkyard, Zoning and Land Use Permits
Online Taxes
Residents
Solid Waste Department
Social Services Department
Board of Elections
Public Transportation
Office for the Aging
Assessment
Real Property
Contact
Town, County and Village Directory
How Do I?
Public Health
Public Health
Public Health FAQ
Calendar
Children with Special Needs
Children with Special Needs Programs Referral
COVID-19 Information
Close Contact
FAQ
Positive Case
Positive Home Test
Testing
Vaccine
Emergency Preparedness
Getting There
News and Alerts
ONLINE PAYMENTS BY CREDIT CARD
Population Health
Preventative Services
Self-Referral Form
General Information
Staff Directory
Director
Ashley Waite, RN, BSN, MPH
(315) 376-5453
ashleywaite@lewiscounty.ny.gov
Location
7785 N State St
Suite 2
Lowville,
NY
13367
Get Directions
Hours
M-F
8:30 AM - 4:30 PM
Follow Us
Children with Special Needs Programs Referral
Home
>
Groups
>
Public Health
>
Children with Special Needs Programs Referral
{}
W10=
To view more details about our programs, please
click here.
*
Please choose one of the following programs:
Child Find
Early Intervention
Preschool
PHCP
CYSHCN
*
Today's Date:
*
Child's Name:
*
Date Of Birth:
*
Sex:
Male
Female
*
Person Making Referral:
*
Phone #:
*
Parent/Guardian:
*
Phone #:
*
Mailing Address:
*
City/Town:
*
Zip Code:
School District:
Harrisville Central School
Beaver River Central School
Lowville Academy Central School
Copenhagen Central School
South Lewis Central School
*
Language Used At Home:
Child's Race:
Child's Ethnicity:
*
Primary Health Care Provider’s Name:
Medicaid Eligible?
Yes
No
Medicaid Number:
Insurance Co.
*
REASON FOR REFERRAL: (ICD-9 Code if applicable)
Auto Qualifier? *FOR DOCTOR'S OFFICES ONLY*
Yes
No
OTHER INFORMATION/DIRECTIONS TO HOME:
Submit
Submit Form
/frontend_forms/resumable_upload/
X
Confirm
Cancel