Refer a Child: Form for Friends, Family Members and Others

In Minnesota and the 11 Tribal Nations we share geography with, infant and toddler early intervention and preschool special education supports happen through the local school districts and cooperatives. If you are a provider or another person supporting the family with this referral, you may make a referral without parent or guardian consent. However, it is strongly encouraged that you share your reason for making the referral and your intent to do so with the family. The local school district or cooperative program will need parental consent to proceed.

Only the items below with a star (*) are required to submit this form. You may also call 1-866-693-4769 for help submitting this form or with any questions about the process. Interpreters are available.

Child's First Name*

Child's Last Name*

Child's Middle Initial

Date of Birth

Child's Age*

Parent is Aware Of This Help Me Grow Referral *

YesNo

Child Resides With*

Parent(s)

Other Family (Grandparents)

Foster Parents

Other

Interpreter Needed

YesNo

Language

Other Language

Contact 1

First Name*

Last Name*

Contact Phone*

Additional Phone

No Phone Available

Email (myname@example.com)

Contact 2 (Optional)

First Name

Last Name

Contact Phone

Additional Phone

No Phone Available

Email (myname@example.com)

Physical Address 1*

Physical Address 2

Zip Code*

City*

State*

Tribal Nation Land, County

If the Family/Caregiver has no phone, please provide an alternative contact

First Name

Last Name

Relationship

Phone Number

Email (myname@example.com)

Your First Name*

Your Last Name*

Your Title

Your Agency Type*

Your Agency*

Your Address 1*

Your Address 2

Your Zip Code*

Your City*

Your State*

Your Phone Number*

Your Extension

Your Fax Number

Your Email (myname@example.com)

In Minnesota and the 11 Tribal Nations we share geography with, infant and toddler early intervention and preschool special education supports happen through the local school districts and cooperatives. The information from this form will submit electronically to the local school district or cooperative where the child lives. The parent or guardian can expect to hear from someone from the local school district or cooperative to discuss next steps. If the family does not receive a call within 7-10 days, they are encouraged to call Help Me Grow for support at 1-866-693-4769. Interpreters are available.

If this referral is being made during the school summer months for a child between the ages of 3 through 5, the parent or guardian may not hear from the school district or cooperative until school is back in session in the fall.

If the referral is being made for a child under the age of three, these services and supports are available throughout the year. If you do not hear from the local school district or cooperative within 7-10 days, please reach out to Help Me Grow at 1-866-693-4769. Interpreters are available.