Parents as Teachers Intake
 Parents as Teachers is an early childhood home visiting program designed to help you learn more about parenting, support your child's development, and help with the challenges of family life.  Our services are available to your family until kindergarten.  Your participation is voluntary and there is no cost.
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Email *
Please indicate your relationship to the child(ren). *
Our services to your family include personal visits, group connections, child screening and a network of resources.    You will be asked to actively participate in all scheduled visits and share your observations of your child.  Parents as Teachers will not release confidential information outside of the program without your written permission with the following exceptions: to protect you or others from serious harm or if we receive a court order for records.
Household parent 1 - Last Name *
Household parent 1- First Name *
Household parent 2- Last Name
Household parent 2- First Name
Phone Number *
Street Address *
City *
Zip Code *
Parent educators are not psychologists or medical professionals.  We do not diagnose developmental, psychological, or medical conditions.  However, we can help you connect to qualified professionals and resources that can assist in these situations.
Number of children aged birth to 5 years? *
Child's First Name *
Child's Middle Name *
Childs Last Name *
Child's Date of Birth *
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Additional Child- Full Name
Additional Child Date of Birth
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YYYY
Please add any additional information here.
A copy of your responses will be emailed to the address you provided.
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