Enroll Form Provider - Help Me Grow

PROVIDER REFERRAL INFORMATION

*Required Label
Person Completing Form*
Name of Organization or Clinic*
City*
Phone*
Fax Number*
Contact Person*
Family Information
Parent/Guardian 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)*
MM slash DD slash YYYY
Child's Gender
Preferred Language
Insurance Name (Example: CCHP, Anthem Blue Cross)
Concerns/Comments*
Race/Ethnicity
I have permission to share family's information*
- YES
- NO
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 checking this box, you as the provider acknowledge having received verbal consent from the parent to this referral to Help Me Grow (HMG) and the parent understands that Help Me Grow will contact them about their child. This includes permission for Help Me Grow and you as the provider to collaborate by sharing the child’s developmental screening results, the resources and referrals provided to the family, and the results of actual resource or referral linkages. To connect a family to Help Me Grow, the parent or guardian needs to provide verbal consent to you.