Root for Kids Referral Form

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We're glad you're here! Let's do this, together.
We know it can feel overwhelming to know where to begin, but rest assured—we’re here and ready to support YOU.
Please fill out the form below, and a member of our team will reach out to walk you through the next steps.
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Which service(s) are you interested in?*

Early Intervention | Utah and Arizona areas (developmental delay, birth - 3 years old)

Kindermusik | Washington County

Early Head Start Home-Based | Washington County (prenatal - 3 years old)

Parents as Teachers | Washington and Iron Counties (home-based, prenatal - 5 years old)

Caterpillar Clubhouse Childcare | St. George (6 weeks - 3 years old)

Family Support Coordination | Arizona Only

Early Head Start Center Based | Hildale (12 - 36 months)

Unsure

Child's Full Legal Name*

If applying for a pregnant mother please put N/A

Child's Gender*

Child's Birthday (MM/DD/YYYY)*

If applying for a pregnant mother please put due date.

Parent/Guardian Name*

Parent/Guardian's Birthdate (MM/DD/YYYY)

Primary Home Language*

Phone Number*

If you do not currently have a phone number please put N/A

E-mail Address*

If you do not currently have an e-mail address please put N/A

Preferred Method of Contact*

Street Address*

Address Line 2 (Apartment Number, Suite, etc.)

City*

State*

Zip Code*

Who is completing this form?

Parent, Physician's Office, Staff Name, etc.

Do you have any concerns about...*

Motor Skills (rolling, crawling, sitting, walking, etc.)

Vision

Hearing

Communication

Behavior

Problem-Solving

Feeding

Sleeping

Health/Diagnosed Condition

No Developmental Concerns

Other

Is there anything else you would like us to know about the child's health and development? *

How did you hear about Root for Kids?*

Please specify (organization, name of physician, community event name, social media platform, school name, etc.)*

2044 S Mesa Palms Drive

St. George, UT 84770

435-673-5353

Employee Login

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We're glad you're here! Let's do this, together. We know it can feel overwhelming to know where to begin, but rest assured—we’re here and ready to support YOU. Please fill out the form below, and a member of our team will reach out to walk you through the next steps. ____

We're glad you're here! Let's do this, together.
We know it can feel overwhelming to know where to begin, but rest assured—we’re here and ready to support YOU.
Please fill out the form below, and a member of our team will reach out to walk you through the next steps.
____