Referral Forms

To make a referral for any of our services, please select one of our forms below.

Note: This information is transmitted and stored using secure encryption technology. 

You may also submit a referral directly to Ileene Therrien via email or fax (802) 229-0101.



We are requesting a change in referral practices for children below the age of three (3) who are diagnosed with a hearing loss.  Presently, many referrals are made directly to the Parent Infant Program at Nine East Network.  We ask that these referrals be made, instead, to Children’s Integrated Services.


By referring directly to Children’s Integrated Services (CIS), you will expedite service delivery to your patients enabling Vermont’s CIS Early Intervention to enroll your patient in services and involving the Parent Infant Program services from the start, with the child’s parent or guardian’s consent.


Referrals to CIS can be made using the referral form.  A fillable version of this form can be found at the following web link:


Your referral can be made by contacting or sending your form to the CIS Coordinator serving the area where the child resides.  A copy of this list can be found at the following web link:


Additionally, VTEHDI is requesting that the diagnosing audiologist mention early intervention in their diagnostic report.  Please include that a referral was completed, early intervention was discussed but deferred by the family, or that EI was not discussed for “X” reason and will be addressed at the next appointment or via a follow-up phone call.


Thank you.

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