Refer a Child: Professional Form

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.

*I have the consent from the parent/guardian to release information beyond the child's name, address and birth date. (Choosing 'No' will still allow you to make the referral)


    Child Information

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

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

    Child Resides With

    Contact 1

    Contact 2 (Optional)


    Your Information

    I am the child's primary doctor

    Child's Primary Doctor/Clinic (if known)

    Reasons for Referral *

    Screening Information

    Has There Been A Developmental Screening Completed Using A Standardized Screening Instrument? *
    Has A Social/Emotional Screening Been Completed Using A Standardized Screening Instrument? *
    Please indicate what information you would like to receive, if any

    The district who receives this referral will only be able to provide this information upon receipt of signed parental consent.

    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.