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 Information

Prenatal Referral

Reason for Referral

Please Help Connect to:

Referring Provider Information

Referrer Mailing Address

Notes Section

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

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/guardian has given permission for information on this form to be shared with Help Me Grow (answer required)