Refer a Child or Family

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

  • Perinatal support and resources
  • Home visiting
  • Treatment and supports for substance use disorder during pregnancy
  • Developmental screening, early intervention and Children’s Integrated Services
  • Child care, preschool, Head Start, playgroups and more
  • WIC and resources for basic needs
  • 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

Unborn Child?

Referring Provider Information

Reason for Referral

Please Help Connect to:
Has a developmental screening tool like the ASQ-3 been completed?
If you are an early childhood special educator, early intervention provider, or other early chilhood professional please answer the following:
Has the child received a comprehensive (five domain) developmental assessment?
Has a referral to the Children's Integrated Services been made?
It is required that the parent/guardian give permission for information about their child to be shared between the referring entity and HMG VT:
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).