Help Me Grow Child Screening Request

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?

Date / Time

Date

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

Yes

Other (please specify)

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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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10. Where did you hear about us?

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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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* 10. Where did you hear about us?

1. Parent Name

2. Child Name

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

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

5. What county do you currently live in?

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

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

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

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

10. Where did you hear about us?