Clermont Help Me Grow
Central Intake and Coordinating Site
P.O. Box 8
Owensville, Ohio 45160
513-732-5030
513-732-5031 (fax)

For more information about Ohio Help Me Grow:
1-800-755-GROW (4769)
www.ohiohelpmegrow.org

Contact Form:
Thank you for visiting Help Me Grow of Clermont County. Please take a moment to fill out the information below so we may better assist you.

Complete the online form below or, Download, complete and mail or fax the completed form to our office. (Adobe Acrobar Reader® is needed to view the document)

Child's Full Name:

Sex: Male Female

Child's SS#:

Date of Birth: (Example: 01/01/2002)

Parent/Guardian Name:

Single Parent:

Address:

City:

State:

Zip:

Responsible School District:

Daytime Phone:

Home Phone:

Best Time to Call:

Caller or Referral Source Name:

Caller or Referral Source Affiliation: Parent/Caregiver or Agency:

Agency Address:

Agency City:

Agency State:

Agency Zip:

Agency Phone:

Agency Fax:

Describe the major concerns at this time. Include services requested or needed. Please be as specific as possible:

Is the parent aware of this referral to HMG? Yes No

Does parent agree to referral to another HMG agency? Yes No

Is the parent receiving service from any other agency? Yes No

If so, list Agency:

Previous EI:

Prenatal Due Date:

When did prenatal care begin:

Gestation:

Birth Weight:

Gravida: (# of pregnancies)

Para: (# of live births)

Names and ages of siblings:

1)

2)

3)

Person completing this form:

Referred to :

Date: