2. Date and Time
   Date and Time

   Date and Time
3. County/ Tribal Agency of Residence
5. Family Information:
7. Parent 1: Parent/ Caregiver Name
8. Date of Birth:
10. Gender
    -- Select One --MaleFemaleNon-Binary/third GenderPrefer not to respondPrefer to self-describe
11. Gender: If self-describing
12. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaskan NativePacific IslanderOtherDeclineUnknown
13. Race: if other please provide
15. Hispanic Heritage
    -- Select One --YesNoUnknown
16. Any Known Disablilities:
    -- Select One --YesNoUnknown
17. Disabilities: if yes, please explain
21. Parent 2: Parent/ Caregiver Name
22. Date of Birth
24. Gender:
    -- Select One --MaleFemaleNon-Binary/ third gender Prefer not to respondPrefer to self-describe
25. Gender: If self-describing
26. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaskan NativePacific IslanderOtherDeclineUnknown
27. Race: if other please provide
29. Hispanic Heritage:
    -- Select One --YesNounknown
30. Any Known Disabilities:
    -- Select One --YesNoUnknown
31. Disabilities: If yes, please explain
35. Other Adult: Name
36. Date of Birth:
38. Gender:
    -- Select One --MaleFemaleNon-Binary GenderPrefer to Self-DescribePrefer not to answer
39. Gender: If self-describing
40. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaska NativePacific IslanderOtherDeclinedUnknown
41. Race: if other please provide
43. Hispanic Heritage:
    -- Select One --YesNoUnknown
44. Any Known Disabilities:
    -- Select One --YesNoUnknown
45. Disabilities: If yes, please provide
49. Children's Information
51. Child (1)
52. Date of Birth:
54. Gender:
    -- Select One --MaleFemaleNon-Binary GenderPrefer to Self-DescribePrefer not to respond
55. Gender: If self-describing
56. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaska NativePacific IslanderotherDeclinedUnknown
57. Race: If other, please provide
59. Hispanic Heritage
    -- Select One --YesNoUnknown
60. Any known disabilities:
    -- Select One --YesNoUnknown
61. Disabilities: If yes, please provide
63. If child is age 5 or under: Has a referral been made for a develpmental screening through Help Me Grow or the local school district?
    -- Select One --YesNoUnknown
65. Child (2)
66. Date of Birth
68. Gender
    -- Select One --MaleFemaleNon-binary GenderPrefer to self-describePrefer not to repsond
69. Gender: if self-describing
70. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaska NativePacific IslanderOtherDeclinedUnknown
71. Race: if other, please provide
73. Hispanic Heritage:
    -- Select One --YesNoUnknown
74. Any known disabilities:
    -- Select One --YesNoUnknown
75. Disabilities: If yes, please describe
77. If child is age 5 or under: Has a referral been made for a develpmental screening through Help Me Grow or the local school district?
    -- Select One --YesNoUnknown
79. Child (3)
80. Date of Birth:
82. Gender:
    -- Select One --MaleFemaleNon-binary genderPrefer to self-describePrefer not to respond
83. Gender: If self-describing
84. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaska NativePacific IslanderOtherDeclinedUnknown
85. Race: If other, please provide
87. Hispanic Heratige:
    -- Select One --YesNounknown
88. Any known Disabilities:
    -- Select One --YesNoUnknown
89. Disabilities: If yes, please describe
91. If child is age 5 or under: Has a referral been made for a develpmental screening through Help Me Grow or the local school district?
    -- Select One --YesNoUnknown
93. Child (4)
94. Date of Birth:
96. Gender:
    -- Select One --MaleFemaleNon-binary/ third genderPrefer to self-describePrefer not to respond
97. Gender: If self describing
98. Race:
    -- Select One --CaucasianBlack or African AmericanAmerican Indian/ Alaska NativePacific IslanderOtherDeclinedUnknown
99. Race: If other, please provide
101. Hispanic Heritage:
     -- Select One --YesNoUnknown
102. Any known Disabilities:
     -- Select One --YesNoUnknown
103. Disabilities: If yes, please describe
105. If child is age 5 or under: Has a referral been made for a develpmental screening through Help Me Grow or the local school district?
     -- Select One --YesNoUnknown
107. Child (5)
108. Date of Birth:
110. Gender
     -- Select One --MaleFemaleNon-Binary/ third genderPrefer to self-describePrefer not to answer
111. Gender: if self-describing
112. Race:
     -- Select One --CaucasianBlack or African AmericaAmerican Indian/ Alaska NativePacific IslanderOtherDeclinedUnknown
113. Race: If other, please provide
115. Hispanic Heritage:
     -- Select One --YesNoUnknown
116. Any know Disabilities
     -- Select One --YesNoUnknown
117. Disabilities: If yes, please describe
119. If child is age 5 or under: Has a referral been made for a develpmental screening through Help Me Grow or the local school district?
     -- Select One --YesNoUnknown
121. Family Street Address:*
123. City*
124. State*
125. Zip Code*
127. Phone Number
128. Cell Number
130. Email Address (if known)
134. Are any family members enrolled or eligible for enrollment with any federally recognized American Indian Tribe?*
     -- Select One --YesNo
135. If yes, which household memeber(s)?
136. If yes, which tribe?
138. Does the Family speak English?*
     -- Select One --YesNo
139. If no, what is the preferred language of the family?
140. If no, is an interpreter needed?
     -- Select One --YesNo
144. Eligibility Information:
146. Does the Family have a child age 10 or under?
     -- Select One --YesNo
147. Is the parent/ caregiver pregnant?
     -- Select One --YesNoUnknown
148. Does the family have current involvement with child protection?
     -- Select One --YesNoUnknown
150. What are the family's identified stress factors? Check all that apply

     1. Domestic Violence
     2. Homeless/ housing concerns
     3. Child behavior concerns
     4. School/ education concerns
     5. Trauma exposure
     6. Mental health concerns(parent of child)

     1. Parent/ caregiver separation
     2. Limited support system
     3. legal issues
     4. Grief/ loss
     5. Chemical use concerns (parent of child)
     6. Prior child protection history

     1. Disability (parent or child)
     2. Medical Concerns (parent or child)
     3. Low income/ poverty
     4. Parenting challenges
     5. Human/ sex trafficking concerns
     6. Other
152. What is/ are the reason(s) for this referral
154. Are there immediate safety concerns for the family? If yes, describe:
156. What are the family's strengths and known supports?
158. Share any additional information necessary for this referral:
160. Does the Family know about the referral?*
     -- Select One --YesNo
164. Referring Source Information
166. Name*
167. Role with family/ profession
169. Address
171. City
172. State
173. Zip Code
175. Phone Number*
176. Email Address
Leave This Blank:


178. 1. Receive an email copy of this form.
179. Email address

     This field is not part of the form submission.

180. Submit Submit and Print

* indicates a required field