Start services · Peter Project Outreach

Welcome

We are so glad you are here, and we look forward to learning how we can support you.

You will enter each detail only once. We carry it through the whole packet for you. Extra questions appear only when they apply.

For a text box that does not apply, type N/A. Use the choices provided for dates, phone numbers, IDs, and permissions.

If a child is in danger right now, please do not use this form.
Call 911, call or text 988, or call the Harris Center at 713-970-7000.

🧒About the child

Basic information, home, language, and school.

Child information

Asked once and reused throughout the packet

First name

Last name

Preferred name

Date of birth

Sex on insurance record

Optional identity details

Gender or pronouns

Race

Ethnicity

Home and school

Use N/A for a text box that does not apply

Home address

City

State

ZIP

Preferred language

Interpreter needed?

School or daycare

Optional household and school details

Who does the child live with?

School contact

Why may school coordination help?

🧑Parent or legal guardian

Who we should call and who may give permission.

Contact information

Your name will also fill the signer line

Your full name

Relationship to child

Cell phone

Home phone

Best time to reach you

Legal authority

Guardian photo ID

Upload now or provide it later

Take a clear photo or choose a JPG, PNG, or PDF. The front is usually enough; add the back when it contains identifying information. You may submit without documents. Any file you choose must be prepared successfully or removed before submitting.

Your documents are used to verify guardian identity and insurance. Upload only the requested insurance card and guardian photo ID. Do not upload a Social Security card, banking document, or payment-card information. Use these upload buttons—not email or text.

Front of guardian ID JPG or PNG photo up to 12 MiB, or PDF up to 5 MiB. We resize photos before sending.

Back of guardian ID Optional. JPG or PNG photo up to 12 MiB, or PDF up to 5 MiB. Add only when the back contains identifying information.

Emergency contact

Someone other than the parent or guardian, when available

Name and relationship

Phone

Does the guardian know about this referral?

Yes, expecting our call Not yet I am the guardian

I confirm that I am authorized to consent for this child.

Yes, I confirm No

💳Health coverage

Enter each ID exactly as it appears on the card. We do not guess one ID from another.

Primary coverage

Use Not sure if you do not have the card

Health plan

Medicaid ID

Member or policy number

Group number

Upload a clear image of the primary Medicaid or insurance card. The form labels it as a Medicaid card when a Medicaid ID is entered; otherwise it is sent as an insurance card. You may submit without a file and provide it later.

Front of primary card JPG or PNG photo up to 12 MiB, or PDF up to 5 MiB. We resize photos before sending.

Back of primary card Optional. JPG or PNG photo up to 12 MiB, or PDF up to 5 MiB. Upload the back when it contains plan or contact details.

Other health insurance

Work plan, another parent's plan, TRICARE, or CHIP

Other health insurance besides Medicaid?

Yes No Not sure yet

✅Permissions

Required acknowledgments start blank. Optional choices may be accepted, declined, or left for later.

Optional care choices

Each choice is separate

Telehealth sessions

Family participation

Approved transportation coordination

Follow-up after care or missed contact

School coordination

A separate release may still be required before protected information is shared with another person or organization.

📱Text and email

All choices are optional and begin unchecked. Saying no does not affect services.

💬

Appointment and care texts

✉️

Appointment emails

📄

Email copies of documents I already signed

Only to the email address entered above.

✨

Occasional program news or event texts

Separate from care messages. Reply STOP to stop all texts.

✍️Review and sign once

Drawing is optional. You may type your full legal name below instead.

Signer name Filled from the name entered earlier. You may correct it before signing.

I confirm that the signature or typed name above is my electronic signature and that the information is accurate.

Thank you,

Everything reached our intake team.

What happens now

We read what you sent and check coverage
We reach out in 1-2 business days
We arrange next steps and agree a plan with you

Need us sooner? Call (281) 985-5220, Monday to Friday, 9:00 a.m. to 7:00 p.m.