About
Family Engagement Model
Implementation
Learning Institute
Our Team
- Our Team
- Join Our Team!
News & Events
Support Us
- Invest
- Benefactors
Founding Program – Decatur, IL
Contact Us

About
Family Engagement Model
Implementation
Learning Institute
Our Team
- Our Team
- Join Our Team!
News & Events
Support Us
- Invest
- Benefactors
Founding Program – Decatur, IL
Contact Us

Newborn Encounters
Community Outreach Programs
Teen & Adult Education
Home Visiting
Center-Based Education
Resources
Register for Services

Register for Baby TALK Services

Baby TALK Programming is available to prenatal mothers and families with children 0-3 years of age.

A representative from Baby TALK will contact you for more information.

______________________________________________________

PARENT/GUARDIAN 1

Are you the custodial parent? *

Yes
No

Name *

First

Middle

Last

Date of Birth *

Street Address - include Apt. # if applicable *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

May Baby TALK Text/Email you? *

Yes
No

Race/Ethnicity *

Language Spoken

Gender

Education

Marital Status

Married
Single
Widowed
Divorced
Separated

Military Connected

Yes
No

Employment Status *

Current Employer

______________________________________________________

PARENT/GUARDIAN 2

Are you the custodial parent?

Yes
No

Name (parent/guardian 2)

First

Middle

Last

Date of Birth

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

May Baby TALK Text/Email you?

Yes
No

Race/Ethnicity

Language Spoken

Gender

Education

Marital Status

Married
Single
Widowed
Divorced
Separated

Military Connected

Yes
No

Employment Status

Current Employer

______________________________________________________

CHILD'S INFORMATION

Child's Name *

First

Middle

Last

Child's Date of Birth *

Gender of Child *

Race/Ethnicity *

Language Spoken

Does your child have an IFSP (Individualized Family Service Plan)?

Yes
No

Is your child enrolled in another program?

Yes
No

If yes, where?

______________________________________________________

FAMILY COMPOSITION & RESOURCES

Family Structure of Home - Check all that apply *

Two Parent home
Single Parent home
Living with Grandparents
Living with other relatives
Living in an extended family
Living with Guardian
Living with Foster Parent
Homeless
Other

*Homeless: Individuals who lack a fixed, regular, and adequate nighttime residence.

If "Other" please describe

DCFS Involvement *

Yes
No

______________________________________________________

OTHER HOUSEHOLD MEMBERS

Name

First

Last

Date of Birth

Relation to child

______________________________________________________

Name

First

Last

Date of Birth

Relation to child

______________________________________________________

Name

First

Last

Date of Birth

Relation to child

______________________________________________________

Name

First

Last

Date of Birth

Relation to child

______________________________________________________

Types of Services or Financial Assistance (received by child and his/her parent) *

No Assistance received
Medical Assistance (Medicaid/All Kids)
Food Stamps/Link Card
Energy Assistance (LIHEAP)
WIC/Better Birth Outcomes
Public Housing Assistance
Foster Care/ Adoption Subsidy
Unemployment Payments
Cash Assistance/TANF
Child Care Subsidy/ CCRS
Child Support/Alimony
Receive SSI Payments
Home Visiting
Other

* Select All That Apply

Types of Transportation *

Own Vehicle
City Bus
Family/friend
No transportation

Is there anything else you would like to tell us about your child?

Baby TALK’s mission is to positively impact child development by nurturing healthy and responsive relationships during the critical early years.

Main Office

355 E. Marietta St.
Decatur, IL 62521

(217) 475-2234

contact@babytalk.org

Register for Baby TALK Services

Baby TALK Programming is available to prenatal mothers and families with children 0-3 years of age.

______________________________________________________

PARENT/GUARDIAN 1

______________________________________________________

PARENT/GUARDIAN 2

______________________________________________________

CHILD'S INFORMATION

______________________________________________________

FAMILY COMPOSITION & RESOURCES

______________________________________________________

OTHER HOUSEHOLD MEMBERS

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Main Office

MENU

Help us make a difference

Baby TALK is an evidence-based FAMILY ENGAGEMENT model.