Children's Therapeutic Learning Center in Kansas City | Infant Toddler Services


	Referral Form Please fill out the information below. This is just a referral form, not a registration application. After your form has been submitted, you will be contacted by the agency Social Worker for further information.
	I am making a referral for Services at:* Children's TLC Wyandotte County Infant-Toddler Services


	Child Information Please fill out the following for the child you are referring to Children's TLC.
	Child's Name* (First Name ) (Last Name)
	Age*
	Date of Birth* mm/dd/yyyy


	Parent/Guardian Information Please fill out the following for the Parent or Guardian of the child being referred.
	Parent/Guardian Name* (First Name) (Last Name)
	Address 1* (City) (State) (Zip Code)
	Home Phone*
	Cell Phone
	Email*
	Reason for Referral*
	How did you hear about Children's TLC?*

Referral Form