PROVIDERS

REFER A FAMILY

REFER A CHILD OR FAMILY

By completing this form, you are referring a family to receive:

  1. A Care Coordinator, who will connect families to information and resources on child development, pregnancy, and family support.
  2. Access to screening tools for the developmental and social-emotional health of their child(ren).

With the family’s permission, please fill out the entire form below. After submitting this form, a member of the Help Me Grow team will contact the family. We typically contact the family within 24 hours of receiving a referral, however, please contact the Help Me Grow main office if the family has not been contacted within a week of submission.

HELP ME GROW REFERRAL FORM

 
 
 
   
 

Family Information

 
 
 
 
 
 
 

Child’s Date of Birth (or Due Date):

   
   
   
   
 

Nearly 85% of brain development occurs in the first few years of life.

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Help Me Grow Alabama

Help Me Grow Alabama is a program of the Alabama Partnership for Children as an affiliate of the Help Me Grow National Network.

 

Help Me Grow Alabama is funded by the Alabama Department of Early Childhood Education through the Preschool Development Grant, the Alabama Department of Human Resources, and the Alabama Department of Mental Health through a Project LAUNCH Grant from the Substance Abuse and Mental Health Services Association. In addition, Help Me Grow Alabama is supported by an AmeriCorps State Grant from the Corporation for National and Community Service provided by The Governor's Office of Volunteer Services.

 

HelpMeGrow Partner

HelpMeGrow Partner

HelpMeGrow Partner

HelpMeGrow Partner