Enroll in Healthy Parents & Babies, an Early Head Start Program

Healthy Parents & Babies Application Form

Thank you for your interest in enrolling in our Healthy Parents & Babies program, in Illinois.

We serve families prenatally through birth, and up to age 3 for their children. Persons must be pregnant to qualify for doula services, but can be of any age and at any stage of their pregnancy. Parents can qualify for our home visiting services at any point post-birth through the age of 3 for their children. To get started in the enrollment process, please complete this initial application form and someone from our team will be in touch with you within 3-5 business days.

Note: Participation is not limited to first-time parents or new participants, but everyone must meet Early Head Start income eligibility guidelines in order to qualify.

See Eligibility Guidelines

Primary Parent or Guardian Information

First Name

Last Name

Phone Number

What is the best way to reach you?

What is the best time to reach you?

Zip Code

By providing your zip code, we are able to share resources and program referrals relevant to your location.

What is the primary language spoken at home?

How did you hear about Start Early's Healthy Parents & Babies programs?

Please share the name of the community agency.

Please share the name of the parent or friend who referred you to Start Early.

Other (please specify)

Services for Pregnant Women

Are you pregnant?

YesNo

Is your pregnancy high risk?

YesNo

What is your expected due date?*

Your expected due date (MM/DD/YYYY)

Services for Children Under Age 3

Do you have a child or children that you would like to enroll in Healthy Parents & Babies?

YesNo

Child's First Name

Child's Last Name

What is your child's birthday?*

Your child's birthday (MM/DD/YYYY)

If you are enrolling more than one child, please click "enroll another child" to include their information.

Have additional questions or comments? Add them here.

If you have additional questions, please call 773-312-7881 or email HPB@StartEarly.org.

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Healthy Parents & Babies Application Form