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Parents Know: Help Me Grow
Refer a Child Online
 

Refer a Child: Professional Form

All items that are marked with a star(*) must be completed in order to submit the referral to Minnesota Help Me Grow. If you are not the parent or guardian, you may make a referral anytime, but please speak with the child's family first. Help Me Grow staff will contact them for their permission to proceed with the referral, and they may accept or decline.

 
 

Child Information:

 
Child's First Name*:
Child's Last Name*:
Gender*:
Child's Age*:
Date of Birth:
(MM/DD/YYYY)
Child resides with:
Primary language spoken at home:
if Other: 
 
Interpreter Needed:

Child resides with:

Contact 1
  First Name:
  Last Name:
Contact 2
  First Name:
  Last Name:
Street Address 1*:
Street Address 2:
City*:
ZIP Code*:
County:
Contact Phone:
 

If the family has no phone, please provide an alternative contact:

First Name:
Last Name:
Relationship:
Phone:
 

Your Information:

 
Reasons For Referral*:
 
 
Your First Name*:
Your Last Name*:
Agency:
Address 1*:
Address 2:
City*:
State*:
ZIP Code*:
Phone*:  Ext: 
FAX:
Email:
 
 

Child's Primary Doctor/Clinic (if known):
Doctor's Name:
Clinic Name:
Address 1:
Address 2:
Phone:
City:
State:
ZIP Code:
 
Parent is aware of this referral to Help Me Grow Services*:
 
 
 
If needed, you may briefly provide additional information about this referral to Help Me Grow program and services in the comment box below. (Please note comments are limited to 500 characters.)
 
 


If you have any concerns about your child's growth and development, please talk to your child's health care provider or call 1-866-693-GROW to talk to a professional and find out ways in which you can get connected to various resources in Minnesota.