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?

Please provide your current address. Please note that addresses are kept confidential and are only utilized to recommend the closest program to your residence.

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 program?

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)

INCOME

Do you currently meet the income eligibility guidelines for our pre and postnatal services?

YesNoI don't know

UNABLE TO PROCESS APPLICATION

It looks like you selected that you do not meet the income requirements according to the federal poverty guidelines, which means you will not be eligible for Healthy Parents & Babies services. We appreciate your interest but will not be able to process your inquiry.

BEFORE CONTINUING

If you are unsure if you meet our income eligibility standards, please review the federal poverty guidelines to make your determination, or please reach out to our team at 773-312-7881, or email HPB@StartEarly.org, to help in this determination.

Services for Pregnant Women or Birthing People

Are you pregnant?

YesNo

BEFORE YOU CONTINUE

If you are not currently pregnant, but do have a child, or children, Healthy Parents & Babies serves children and their families through age 3 for our home-based, home visiting services. If you are looking for center-based child care for children ages birth - 5, please visit our Early/Head Start Network child care page for more information.

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.

ALTERNATIVE OPTIONS

It looks like you selected that you are neither pregnant, nor have a child who is 3 and under that you would like to enroll, which means you will not be eligible for Healthy Parents & Babies services. Looking for home or center-based child care for your child? Please visit our Early/Head Start Network child care page for more information on our community based agencies that serve children and their families up to the age of 5.

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

Have any additional questions? Add them here.

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Healthy Parents & Babies Application Form