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 ***
ASQ Online Service
The Ages and Stages Questionnaire (ASQ) is a free developmental screening tool available statewide for families with children birth through age 5. The ASQ tracks a child’s developmental milestones, identifies strengths, and helps parents and caregivers learn whether there are any concerns. Get personalized results and support from a developmental screening specialist.
Early Intervention
Early Intervention supports families of children birth to age 3 who have developmental delays or disabilities so they have the best possible start in life. Professionals help identify a child’s strengths and needs, addressing concerns as early as possible. Services are provided where families live, play, and spend their day. There is no need to “wait and see.” Concerned about a child’s development? Act early!
Family Connects
Family Connects is a free, in-home nurse visit provided within the first few weeks of a newborn’s arrival. Visits are offered to all families who reside in a participating area. The nurse checks up on the baby’s and the family’s health, screens for potential postnatal health complications, answers questions about welcoming a newborn, and connects the family to resources within their community.
Home Visiting
Home Visiting is a family support program for pregnant individuals and caregivers with young children promoting healthy growth and development. Each home visit, tailored to a family’s needs, provides support for a healthy pregnancy; tips to help a child stay safe and learn; and an opportunity to ask questions, share concerns, and connect with community resources
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.