Refer a Family

When you refer a family to our services, you can be sure that we will follow up with a phone call as soon as possible to address their specific needs. Our relationships with the children and families we serve last as long as they continue to need us. Let us know who could use our help!

Don’t need to refer a family to Help Me Grow Alaska but would like help finding a resource or service for one of the families you treat? Give our Family Support Specialists a call and we’ll be happy to help you by providing all the information you request.

If you would like to refer a family to our services, you may use the form below, or fax a referral form to our office. You may use your office’s internal referral form, or use the Help Me Grow Alaska Provider Referral Form.

Help Me Grow Alaska Call Center Phone Number: (833) 464-2527

Help Me Grow Alaska Fax Line: (833) 697-0478

*Marks a required field.

Refer a Family

Your First Name *

Your Last Name *

Title

Practice or Agency Name *

Your Phone Number *

Your Email

Child's First Name *

Child's Last Name *

Child's Age *

Do the parents or caregivers know that you are referring their child to our services?

Yes

Family Contact (Parent or Caregiver) First Name *

Family Contact (Parent or Caregiver) Last Name *

Family Contact's Relationship to Child

Family Contact (Parent or Caregiver) Phone Number *

Reason for Referral to Help Me Grow Alaska *

reCAPTCHA

If you are human, leave this field blank.