HELP ME GROW REFERRAL FORM West Virginia Help Me Grow is

HELP ME GROW REFERRAL FORM
West Virginia Help Me Grow is a free parent information and referral telephone service
designed to connect families to information about child development and community
resources.
Here are three reasons for you to refer a child:



To connect parents from all backgrounds with trained experts who will locate
community services to meet the critical developmental needs of their children,
birth through age 5.
To save time researching community referrals in your office.
Help Me Grow uses the Ages and Stages Questionnaire, Third Edition (ASQ-3)
which is endorsed by the American Academy of Pediatrics to assist in early
detection of possible developmental delays.
Please provide the requested information below about the referred child or you can call
(800) 642-8522 to make a phone referral.
Referring Agency:
Contact Name:
Address:
City:
State:
Zip Code:
Phone:
FAX:
Email:
Additional Comments:
Child’s Name:
Male
Female
Date of Birth:
Phone:
Parent/Guardian Name:
Address:
City:
State:
Zip Code:
County:
Questions, call 800 642-8522 or
Visit our website: www.dhhr.wv.gov/helpmegrow
FAX: 304 957-0444
WVDHHR/BPH/OMCFH/HelpMeGrowReferralForm09/02/2014