Registration Form

Parents as Teachers Intake Form
Your child was born to learn -
and you are their most important teacher.

Parents as Teachers is a free home visiting program that aims to empower you to parent with confidence and raise a child that is healthy, safe, and ready for school.

During a home visit, your Parent Educator will:
- Share information about every stage of your child's development
- Demonstrate ways to help your child learn through play to enhance their skills
- Provide materials for you and your child to connect through activities, games, and crafts
- Connect you to resources that can help your family
Thank you for your interest. Please take the time to fill out the registration form below.
Parent/Caregiver Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver Birth Date*

MonthDayYear
E-mail
Phone Number*
Format: (000) 000-0000.
Can we text you at this number?*

YesNo
Parent/Caregiver Race*
Parent/Caregiver Ethnicity*
Parent/Caregiver Gender:

FemaleMaleNon-binaryOther
Marital status
Select all that apply for you and/or your child(ren):

First-time parentTeen pregnancy/parent under the age of 21Limited/non-English speakingPhysical or cognitive disabilityAlcohol/drug useMental health concernsCurrent/recent incarcerationHousing instability/homelessnessPrevious history of a child removed from careMedical condition affecting pregnancyChild born premature (before 37 weeks gestation)Child born with very low birth weight (less than 3lbs and 4oz)Intimate partner violenceChild abuse or neglectLow income (eligible for public housing, childcare subsidy, WIC, food stamps/SNAP, TANF, and/or Medicaid)Recent immigrant or refugee familyHigh school diploma not attainedNone of these applyOther
Are you currently pregnant?

YesNo
If yes, what is your due date?

MonthDayYear
Date
Do you have children?

YesNo
If yes, what are the children's names and dates of birth?
Is there a second parent/caregiver in your family you would like to add?

YesNo
Second Parent/Caregiver Name*

First NameLast Name
Second Parent/Caregiver Birth Date*

MonthDayYear
E-mail
Phone Number*
Format: (000) 000-0000.
Can we text them at this number?*

YesNo
Second Parent/Caregiver Race*
Second Parent/Caregiver Ethnicity
Primary language spoken in the home:
Please provide additional household members that were not already mentioned below: (names/relationship to child)
Are you an agency submitting a referral for a family?*

YesNo
Referring Agent Name*

First NameLast Name
Referring Agency Company Name*
Job Title*
(Ex. Case Manager)
Phone Number of Referring Agency*
Format: (000) 000-0000.
Email of Referring Agency*
example@example.com
What are you hoping to get out of the program?

Learn about child development and parentingSupport for educational attainment and/or employmentSupport on family planningSupport for maternal health and well-beingIncrease social supportSupport/information on family planningSupport for meeting economic and/or housing needsSupport for mental health
Additional Comments
Should be Empty:

Parents as Teachers Intake Form