Refer a Child: Form for Parents

The information you provide on this referral form will be used to connect you with your local infant and toddler intervention or preschool special education program. Your referral will go directly to your local school district. You do not have to give us specific information about yourself or your child.

After receiving this referral your school district will arrange for program staff to contact you to discuss your concerns and next steps.

The Minnesota Department of Education will use the referral information to evaluate Minnesota’s Help Me Grow referral process. Your child's personal information will not be used in any reports on this process (Minnesota Statute 13.32 is the law that protects the personal information you provide on this form).

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.

    Child Resides With*
    Interpreter Needed

    Child Resides With

    Contact 1

    Contact 2 (Optional)


    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.