Help Me Grow was designed to create an opportunity for parents to track their child's developmental growth and provide peace of mind. After completing the survey below a Help Me Grow Program Specialist will contact you within 2 business days to complete your child's developmental screenings.

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* 1. Parent Name

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* 2. Child Name

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* 3. What is your child's date of birth?

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* 4. Are there other children in the home that also need to be screened?

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* 5. What county do you currently live in?

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* 6. What is the best time of day to contact you about screening your child?

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* 7. What is the best phone number to use when contacting you about screening your child?

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* 8. At what email address would you like to be contacted?

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* 9. Please list any concerns you have regarding your child's development.

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