Child’s name: Child’s date of Birth:

Male:  Female:  

Was your child born early?  Yes:  No:   

If yes, how early?

Parent or guardian name:

Phone:

Email:

Address:

City: Zip Code:

How did you hear about Help Me Grow?
CCR&R Mountainlands Family event Family member Friend Health Department Hospital Internet Newspaper article Online Chat Pediatrician Professional Referral Referral from 2-1-1 center Sub for Santa Welcome Baby Other

If other, please specify:


How can we best assist you (check all that apply)?

Help you with a concern you have with your child

Find community resources for you, your child, and/or your family

Send you the Ages and Stages Questionnaire-our child development screening tool

Comments:

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