Help Me Grow (HMG) is a program for Ohio's expectant parents, newborns, infants and toddlers that provides health and developmental services so children start school healthy and ready to learn.  HMG can assist you if you have concerns about a child’s development.

If you have concerns about an infant or toddler’s language, feeding, walking, handling of toys, seeing, hearing or playing alone or with others, you can call HMG at 1-800-755-4769 (GROW) to be connected to your local HMG program or you may complete and submit the referral form below. The referral information you submit goes to the local HMG in your county and they will contact you. 

All items that are in red and starred must be completed in order to submit the referral.

If you are not the parent or guardian, you may make a referral anytime, but please speak with the child's family first.  Help Me Grow will contact them for their permission to proceed with the referral, and they may accept or decline.

This page last updated on 03/08/07.

Referrer Information Form

Referral Type:	Please Select Family Member Professional Other
Your First Name:
Your Last Name:
Agency:
Address 1:
Address 2:
City:
State:	Please Select Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Deleware Florida Fed St of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri N Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Phone:	Ext
Fax:
Email:

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Minimum Information for Child

Child First Name:
Child Last Name:
Gender:	Male Female
Date of Birth: (MM/DD/YYYY)
Child Resides With:	Parents Mother Father Guardian
Child Resides With First Name:
Child Resides With Last Name:
Address:
County:	Select County Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Indiana Jackson Jefferson Kentucky Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Michigan Monroe Montgomery Morgan Morrow Muskingum Noble Other Ottawa Paulding Pennsylvania Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Unknown Van Wert Vinton Warren Washington Wayne West Virginia Williams Wood Wyandot
Phone: *	No Phone Available
Work Phone:	Ext
Best Time To Call:
Primary Language Spoken in the Home:

If the Family has No Phone:

No Phone - First Name:
No Phone - Last Name:
Relationship:
Phone:*	Ext
Best Time To Call: