Help Me Grow Referral

Referral for Services

Making a referral to Help Me Grow is the first and easy step for parents who have questions or concerns about their infant or child. One referral to Help Me Grow opens the door to many programs that support families including Early Intervention, Home Visiting, Moms and Babies First, and the WIC Program.

If you are not the child’s parent, you may still make a referral. Help Me Grow will first contact the child’s parent before proceeding.

Referral Source

Required Field

Who is Making the Referral

How Did You Hear about Help Me Grow?

Your First Name:

Your Last Name

Agency/Organization:

At least one contact method is required (email, phone, or address)

Email:

Your Phone Number

Street Address

Please complete the referral source street address

City

Please complete the referral source city

Zip

Please complete the referral source zip

County

Caregiver Contact Information

Required Field

Primary Caregiver First Name

Primary Caregiver Last Name

Primary Caregiver Relationship to Child(ren)

Primary Caregiver DOB

Caregiver DOB Cannot Be Future Date Caregiver DOB is invalid. Please correct the DOB

At least one contact method is required (email, phone, or address)

Primary Phone Number

Best Contact Time

Street Address

Please complete the caregiver's street address

City

Please complete the caregiver's city

Zip

Please complete the caregiver's zip

County

Email Address

Preferred Contact Method

Primary Language Spoken in the Home

Primary Caregiver is Currently Pregnant?

Yes No

Additional Caregiver / Alternative Contact

First Name

Last Name

Phone

Relationship to Primary Caregiver

Child(ren) Information One of the Children listed below has a date of birth in the future
One of the Children listed below has a date of birth out of range, should be 12 years or younger
One of the Children listed below has an invalid DOB. Please correct the DOB

Child #

Child's Date of Birth:

Due Date:

Child Due Date must be between 4/14/2020 and 4/28/2022
Child Due Date is invalid. Please correct the Due Date

Child First Name:

Child Last Name:

Child's Gender:

Child Resides With:

Are there concerns about this child's development?

Yes No

Is there a diagnosed medical condition that could cause a delay in development?

Yes No

To which service(s) are you interested in making a referral?

Home Visiting

A service for pregnant or new parents seeking a little extra support to ensure a healthy pregnancy, and to help their child off to the best possible start in life.

I am interested in Home Visiting Services for this family

Early Intervention

Early Intervention is a statewide system that provides coordinated early intervention services to parents of eligible children under the age of three with developmental delays or disabilities.

I am interested in Early Intervention Services for this family

WIC

WIC provides nutrition education and breastfeeding support; supplemental, nutritious foods and iron-fortified infant formula; and referrals to health care and other programs for income eligible pregnant and breastfeeding women, women who recently had a baby, infants, and children up to five years of age.

I am interested in WIC Services for this family

Additional Information

Please briefly tell us why you are seeking Help Me Grow Support