Refer a Child: Form for Friends, Family Members and Others

If you are not the parent or guardian, you may make a referral without parent consent for children birth to kindergarten. We encourage you to speak with the family about this referral. The local infant and toddler intervention or preschool special education program will contact the family for their permission to proceed with the referral. Parents may accept or decline.

Starred (*) fields are required. You can also call 1-866-693-4769 to refer a child.


    Child Information

    Each child must be referred individually. You will be given the option to 'Refer another Child' when you complete this referral.

    Parent is Aware Of This Help Me Grow Referral *
    Child Resides With*
    Interpreter Needed

    Child Resides With

    Contact 1

    Contact 2 (Optional)


    Your Information

    Where did you hear about Help Me Grow?
    Choose all that apply

    The information contained in this form will be submitted electronically to the local school district where the child lives. The parent or guardian should expect to hear from the school district within the next seven to 10 days to discuss the referral.

    If the referral is being made during the summer months for a child between the ages of 3 through 5, the parent or guardian may not hear from the school district until school is back in session in the fall.