Request Assistance

Please fill out the form below if you would like to request assistance from Infants and Toddler Services of Johnson County.

Contact Information



Who referred you?



City, State, Zip:

Parent Information

Mother's Full Legal Name:

Mother's Employer:

Father's Full Legal Name:

Father's Employer:

Child Information

Child's First Name:

Child's Middle Name:

Child's Last Name:

Child's Date of Birth:

Was your child born prematurely?

If yes, how many weeks gestation?

Child's Birth Weight:

Child's Doctor:

Other than English, please list any languages spoken in the home:

Are you currently enrolled in the Parents As Teachers program with your local school district?

If you receive home visits from PAT, who is your parent educator?

Does your child attend daycare, preschool or a Parents Day Out program?

If so, where?

What days and times?

Is there a day during the work week (Monday through Friday) that your child is home with a parent?

Please describe your concerns about your child's development in detail: