Build Up Michigan

Build Up Michigan is for children ages 3-5. If you are concerned about your child or a child you know who may not be meeting important developmental milestones, complete the Referral Form below to begin the evaluation process. Services are FREE and coordinated through the school district where the family resides-even if the child is not yet attending school.

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Build Up Michigan Referral Form

Provide COMPLETE parent/guardian info below. Without complete contact info we have no way to contact a family, which significantly delays processing. For questions, please contact Andrea Martinez or 517.244.4514.

Primary language spoken in the home?

Do you need an interpreter? Yes No

Child Information:

First Name

Middle Name/Initial

Last Name

If the child has gone by a different name/legally changed name(s), please list.

Child's Birthdate MM/DD/YYYY

Child's Race (required) American Indian or Alaska Native Asian American Black or African American Native Hawaiian or Other Pacific Islander White Hispanic or Latino Unknown

Child's Gender Male Female

What school district do you reside?

Referral Reason: What concerns do you have for this child? Please be specific.

Has this child ever received any services such as Early On, Speech, Occupational or Physical Therapy? If so, please list.

This section is for Parent/Guardian contact information ONLY. There is no way for a district to contact a family without COMPLETE contact information.

List Parent/Guardian 1 First & Last Name

Parent/Guardian 1 Relationship to Child

List Parent/Guardian 2 First & Last Name

Parent/Guardian 2 Relationship to Child

Parent/Guardian Primary Email Address Help for Parent/Guardian Primary Email Address The majority of communication is via email. By not including the PARENT/GUARDIAN email address, important communication may be missed.

Parent/Guardian Primary Phone Number

Alternate Phone Number