Enroll Form Parent - Help Me Grow

PARENT/CAREGIVER SELF REFERRAL FORM

*Required Fields
Parent/Caregiver Name*
Phone*
Full Address*
Best Form of Contact*
- Phone
- Email
- Text
Email
Best Time to Contact Parent (Call center available 24 hours a day, 7 days a week)*
Child's First and Last Name*
Child's Date of Birth (or Due Date)*
Preferred Language
Insurance Name (Example: CCHP, Anthem Blue Cross)
How can we best help you? (check all that apply)
- Answer a question/concern about a child
- Help you find community resources
- Connect to developmental screening tool (the Ages and Stages Questionnaire)
- Age appropriate Activities
- Send information on Pregnancy
Concerns, comments, or questions?
Race/Ethnicity
Consent*
- Yes, I agree
Contra Costa Crisis Center has been contracted by First 5 Contra Costa to serve as the Help Me Grow Call Center Specialists at 211. By providing consent, you as the parent or guardian are agreeing to this referral to Help Me Grow (HMG) and understand that Help Me Grow will contact you about your child. This includes permission for Help Me Grow and your provider to collaborate, if needed by sharing your child’s developmental screening results, the resources and referrals provided to your child, and the results of actual resource or referral linkages.