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?
Agency Type:
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 Please correct 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 Please correct the caregiver's zip
(5 digits required)
County:
Email Address:
Preferred Contact Method:
Primary Language Spoken in the Home:
Primary Caregiver is Currently Pregnant?
 
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
To which service(s) are you interested in making a referral?
*** Please choose which service(s) are you interested in is required ***
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.
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.
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.
Additional Information
Please briefly tell us why you are seeking Help Me Grow Support:
After completing the required information above, please click the “Send Referral” button. You will receive a confirmation message and a link to obtain additional information. If you do NOT receive the message, please try again using a different browser. If you still do not receive the message, please contact 1-800-755-GROW or email hmgreferrals@helpmegrow.org to complete the referral process. Thank you.