Referral Form

Refer a Child or Family

One referral to Help Me Grow connects pregnant Vermonters and families with young children to many services like:

Perinatal mental health treatment and supports
Children’s Integrated Services for early intervention, home visiting, mental health services and specialized child care
Treatment and supports for substance use disorder during pregnancy
Developmental Screening (ASQ3/ASQ:SE-2)
Childcare, preschool, Head Start, playgroups, parenting classes and more
WIC and resources for basic needs

Client Insurance

Medicaid/Dr. Dynasaur

Private Insurance

Both Private and Medicaid

Uninsured

Unknown

Has a developmental screening tool like the ASQ-3 been completed?

Yes

Today's Date

By checking here I authorize that the parent/guardian has given permission for information on this form and any accompanying support documents to be shared with Help Me Grow and Children’s Integrated Services.

Refer a Child or Family

Child Information

Reason for Referral

Referring Provider Information

Client Insurance

Refer a Child or Family

Referral Form

Child Information

Reason for Referral

Referring Provider Information

Client Insurance

Notes Section

Auth Section