Are you the primary caregiver for the child? * must provide value
Yes
No
Is your child 5 years old or younger?* must provide value
Yes
No
Help Me Grow only serves children 5 years old and younger. Please contact your pediatrician for information on connection to services or call our care coordination team at 855-475-9211. Are you a service provider requesting services for a single child? * must provide value
Yes
No
Are you a service provider requesting services for a group of children (i.e. child care center)? * must provide value
Yes
No
Are you a therapy provider? * must provide value
Yes
No
Is the child you are referring 5 years old or younger?* must provide value
Yes
No
Help Me Grow South Carolina believes parents are the experts of their children. We require parents be informed when a referral is made on behalf of their child. Is the parent/guardian aware of the referral? * must provide value
Yes
No
Help Me Grow wants to support the relationship you have already established with your client and client's family. Please complete the basic information below and we will contact you with referral recommendations to share with your client and client's family. Age of child you are serving:
Type of insurance for the child you are serving:
Type of resource(s) you are seeking to support your client/client's family:
DO NOT SUBMIT REFERRAL: Help Me Grow SC only serves children 5 years old and younger. Please have this family contact their pediatrician. Help Me Grow South Carolina believes parents are the experts of their children. We require parents be informed when a referral is made on behalf of their child. Please inform the family of this referral before submission. Please choose the role that best describes you: BabyNet Childcare Provider DSS Home Visitor Physician/Physician's Office SCIMHA School District WIC Clinic Child Care Resources and Referrals (CCRR) Department Of Mental Health (DMH) First Steps coach/staff SC Inclusion Collaborative (SCIC) SC Partners for Infant Toddler Care (SCPITC)/Be Well Care Well (BWCW) Other mental health Partnership for Early Attuned Relationships (PEAR) Safe Babies Court Team (SBCT) member Other
If other, please describe:
If other, please describe:
Please choose your home visiting program Early Head Start Early Steps to School Success Healthy Families America Healthy Start Nurse-Family Partnership Parent-Child Home Program Parents as Teachers
Has the family completed the home visiting program? Family has completed the home visiting program
Family has elected to leave the home visiting program
Family has completed the home visiting program
Family has elected to leave the home visiting program
Name of Physician Practice
Practice Address
Primary MD
Phone Number
Fax Number
Name of person making referral
Email of person making referral
Please select the type of therapy provided Speech Therapy
Occupational Therapy
Physical Therapy
Behavioral
Infant/Early Childhood Mental Health
Other
Speech Therapy
Occupational Therapy
Physical Therapy
Behavioral
Infant/Early Childhood Mental Health
Other
If other, please describe:
Provider Name
Please enter your name, email and phone number so we may contact you with referral recommendations for your client.
Name of provider agency
Agency Address
Agency phone number
Agency fax number
Name of person making referral
Email of person making referral
Case Worker Name
Case Worker Phone
Case Worker Email
Case Worker Fax
Reason for DSS involvement
Are you part of the Safe Babies Court Team? Yes
No
Which Safe Babies Court Site? Laurens Orangeburg Spartanburg
Would you like to receive notice of referral outcomes? Yes
No
Child First Name
Child First Name
Child Last Name
Child Last Name
Child's Gender Female
Male
Transgender
Non-Binary
Prefer not to answer
Female
Male
Transgender
Non-Binary
Prefer not to answer
Child's Gender Female
Male
Transgender
Non-Binary
Prefer not to answer
Female
Male
Transgender
Non-Binary
Prefer not to answer
Child's Date of Birth
Child's Date of Birth
Was the child born premature? Yes
No
Was the child born premature? Yes
No
How many weeks premature?
How many weeks premature?
Child's Race (check all that apply) American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Child's Race (check all that apply) American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Child's Ethnicity Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Child's Ethnicity Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Insurance Information Name of Insurance or unknown
Insurance Information Name of Insurance or unknown
Parent/Guardian First Name
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Last Name
Street Address
Street Address
City
City
Zip Code
Zip Code
Parent/Guardian Phone Number
Parent/Guardian Phone Number
Parent/Guardian Email
Parent/Guardian Email
Parent/Guardian Preferred Contact Method Phone
Email
Text
Parent/Guardian Preferred Contact Method Phone
Email
Text
Language to contact the family in English
Spanish
Other
Language to contact the family in English
Spanish
Other
If other, please list preferred language
If other, please list preferred language
Is the referral a result of a developmental screening? Yes
No
Areas of Concern Behavioral
Continued monitoring of development
Fine Motor Skills
Gross Motor skills
Mental Health
Parent support/Education
Prematurity
Social Emotional
Communication
None/Unknown
Behavioral
Continued monitoring of development
Fine Motor Skills
Gross Motor skills
Mental Health
Parent support/Education
Prematurity
Social Emotional
Communication
None/Unknown
mark all that apply
Reason for referral:
Please list all existing services and other referrals in progress:
Attach files
Relationship to Child Parent/Guardian
Resource/Foster Parent
Kinship Caregiver
Parent/Guardian
Resource/Foster Parent
Kinship Caregiver
Please provide the name of the child's DSS caseworker and contact information:
Are you the legal guardian for the child you are requesting services for? Yes
No
Please contact us at 855-476-9211 to discuss options for serving this child. Reason for requesting services:
Best times to contact
Do you consent to receive text messages from our Help Me Grow team? Yes
No
If other, please describe:
Please choose the role that best describes you: Childcare Teacher Childcare Director Childcare Owner Family Childcare Provider SC First Steps CCR&R SCPITC DSS Not affiliated with a center
If not affiliated with a center, please describe your role:
Are the children you serve age 5 or younger? Yes
No
Name of Center
Address of Center
Is this childcare center associated with SC First Steps? Yes
No
Is your center currently enrolled in ABC Quality? Yes
No
Is this childcare center currently receiving infant/early childhood mental health consultation services? Yes
No
Name of IECMH consultant:
Name of person making referral
Email of person making referral
Phone number of person making referral
Reason for referral:
Please provide as much detail as possible without providing child specific identification data
How did you hear about Help Me Grow SC? Physician
Therapy Provider
Childcare Provider
PEAR Consultant
Safe Babies Court Team
HMG Screening Partner
HMG Network Partner
Community Event
DSS
Family/Friend
School District
Website
Social Media
Other
BabyNet
Home Visitor
WIC
SCIMHA
Physician
Therapy Provider
Childcare Provider
PEAR Consultant
Safe Babies Court Team
HMG Screening Partner
HMG Network Partner
Community Event
DSS
Family/Friend
School District
Website
Social Media
Other
BabyNet
Home Visitor
WIC
SCIMHA
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