Refer a Child or Family

HMG Vermont is a free service for all prenatal parents and families with young children through age eight. Fill out and submit this form on behalf of a child or family in order to:

• Connect a parent or caregiver to developmental resources and services

• Request information on child development, pregnancy, or positive parenting skills classes

• Refer a family for a developmental screening

• Get help for a family with navigating social services, problem-solving and advocacy

• Request personalized care coordination to support a child and family

• Receive follow up as a referring provider

For questions, please call us at 2-1-1 x6 or email us at After submitting this form, a child development specialist will contact the parent/caregiver and will also follow up with the referring provider (with parent permission).

The information you submit from this form is safely transmitted in a manner that is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Referral Form

Download File

The parent/guardian must be aware of this referral before HMG VT will contact them. You are required to obtain permission from the caregiver before requesting a referral.

Child & Parent/Guardian Information

Parent/Guardian Address

Referring Provider Information

Referrer Mailing Address

Reason for Referral

Would like help connecting to

Notes Section

Tool like ASQ-3 completed
Has a developmental screening tool like the ASQ-3 been completed?
Referred to Children's Integrated Services
Has a referral to the Children's Integrated Services been made?
If you are an early childhood special educator, early intervention provider, or other early chilhood professional please answer the following:
five-domain developmental assessment
Has the child received a comprehensive (five domain) developmental assessment?

Auth Section

It is required that the parent/guardian give permission for information about their child to be shared between the referring entity and HMG VT:
Authorized permissions
By checking here, I authorize that the parent/legal guardian has given verbal permission to release and use the information on this form (answer required).