Shooting Stars Early Intervention & Therapy Services LLC

Referral Request Form | Now Accepting Referrals

info@mylittlestarsjourney.com | (803) 200-1046

Every Child. Every Family. Every Milestone. Every Star.

Please complete this form so our team can learn more about your family and follow up about next steps. Submission of this form does not guarantee eligibility or enrollment.

Child Information

Child Name Date of Birth Child Age County / State

Parent / Caregiver Information

Parent/Caregiver Name Relationship to Child Phone Number Email Address

Home Address

Services Requested

Developmental Support and Resource Coordination Parent Coaching & Family Support Behavioral Support for Early Learners Spanish-speaking / bilingual support requested

Reason for Referral

Primary concerns, developmental needs, family priorities, or questions

Follow-Up Information

Preferred Contact Method

Phone Text Email

Best Days/Times to Contact Insurance / Funding Source, if known

How did you hear about us?

Additional Family Information

Current services or evaluations, if any What routines are currently most stressful or important for your family? Additional Notes

Consent to Contact

Parent/Caregiver Signature Date