PROVIDERS

REFER A FAMILY

REFER A CHILD OR FAMILY

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

A Care Coordinator, who will connect families to information and resources on child development, pregnancy, and family support.
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.

Your Name*
First Last
Person Completing the Form*
Please indicate the language the family would like to be contacted in:*
Name of organization or clinic:*
Phone*
Fax Number
Email*
Family Information
Parent or Guardian Name*
First Last
Relationship to child*
Parent or Guardian's Phone*
Parent or Guardian's Email:
Best time to contact parent or guardian:
- Morning
- Afternoon
Address
Street Address Address Line 2 City ZIP Code
Child 1 Information
Child's Full Name*
First Last
Child's Gender:*
- Male
- Female
Child's Birthday*
MM slash DD slash YYYY
Was child born early?
- Yes
- No
If yes, how many weeks early?
Has the family given permission to be contacted by Help Me Grow Alabama?*
- Yes
- No
This family has given direct permission for the provider listed above and Help Me Grow Alabama to have ongoing communication, sharing screening results and information about the services provided to the family?*
- Yes
- No
Existing Resources/Referrals in Progress*
Concerns/Reason for Referral*
Child 2 Information
Child's Full Name
First Last
Child's Gender:
- Male
- Female
Child's Birthday
MM slash DD slash YYYY
Was child born early?
- Yes
- No
If yes, how many weeks early?
Has the family given permission to be contacted by Help Me Grow Alabama?
- Yes
- No
This family has given direct permission for the provider listed above and Help Me Grow Alabama to have ongoing communication, sharing screening results and information about the services provided to the family?
- Yes
- No
Existing Resources/Referrals in Progress
Concerns/Reason for Referral
Child 3 Information
Child's Full Name
First Last
Child's Gender:
- Male
- Female
Child's Birthday
MM slash DD slash YYYY
Was child born early?
- Yes
- No
If yes, how many weeks early?
Has the family given permission to be contacted by Help Me Grow Alabama?
- Yes
- No
This family has given direct permission for the provider listed above and Help Me Grow Alabama to have ongoing communication, sharing screening results and information about the services provided to the family?
- Yes
- No
Existing Resources/Referrals in Progress
Concerns/Reason for Referral
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Nearly 85% of brain development occurs in the first few years of life.

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PROVIDERS

REFER A FAMILY

REFER A CHILD OR FAMILY

Family Information

Child 1 Information

Child 2 Information

Child 3 Information

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

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