Connection Form This form is to submit a request for a Navigator to contact your family and connect you with services through Help Me Grow™ North Texas. Parent or Guardian Name* First Last At least one parent/guardian must provide their name for contact information.Additional Parent or Guardian Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State * ZIP Code Email Phone*A Help Me Grow North Texas Navigator will be in contact via phone or email within 48 hours.Best form of contact:* Email Phone Text Best time to contact: Between 8 a.m. and 12 p.m. Between 12 p.m. and 5 p.m. After 5 p.m. Anytime Parent or Guardian Racial Identity* American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Unknown Parent or Guardian Ethnic Identity* Hispanic/Latino Non-Hispanic/Latino Unknown Please contact me in: English Spanish Other Other Language: Are you currently pregnant? Yes No Relationship to the Child* Parent Foster Parent Grandparent Legal Guardian Other Relative Social Worker Case Manager Teacher Other Child's Name:* First Last Child's Gender* Male Female Prefer not to answer Child's Date of Birth:* MM slash DD slash YYYY Child Racial Identity* American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Unknown Child Ethnic Identity* Hispanic/Latino Non-Hispanic/Latino Unknown Questions or concerns about my child: Ask me about my other children when you contact me How did you learn about us?* Call Center 2-1-1 Child Care Provider Community Event Community Training CPS/DFPS Early Childhood Intervention (ECI) Family Resource Center Friend or Family Member Health Care Provider Home Visiting Program (non ECI) Library Mental Health Provider Other Community-based Organization Parent/Caregiver Prior Help Me Grow Client School District Social Media, Internet, News Outlet Therapy Provider (non ECI) WIC Unsure Other
