Parent/Guardian/Family Member or Service Provider Intake Referral

Caregiver Connections

Caregiver Connections provides Early Childhood Mental Health Consultation to child care providers to assist them in understanding and supporting children's social-emotional skills in children from birth to age five.

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* 1. Date:

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* 2. Parent/Guardian Contact Information:

Name:

Phone Number:

Email:

Relationship to the Child:

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* 3. If you are not the parent/guardian, please provide your contact information:

Name:

Phone Number:

Email:

Relationship to the Child/Family:

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* 4. Is the child involved in a DCFS case?

Yes

If yes, please indicate: Placement or Intact

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* 5. Is the child currently receiving therapeutic services, involved with Early Intervention, or the local school district for services (IFSP, IEP)?

Yes

If yes, please explain:

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* 6. Is your child currently attending a child care program?

Yes

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* 7. If your child is attending a a child care program, please provide the child care contact information:

Name of child care program:

Name of contact person at the child care program:

Email:

City:

Zip Code:

Phone Number:

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* 8. Is this child at risk of no longer remaining in the child care program?

Yes

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* 9. Is the child care provider aware you are seeking assistance through Caregiver Connections?

Yes

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* 10. Briefly describe your concern or need:

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* 11. What is the age of the child you are contacting us about:

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* 12. What is the gender of the child you are contacting us about?

Male

Female

Prefer not to answer

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* 13. Please select the race the child identifies as:

Asian

Black/African

Caucasian

Hispanic/Latino

Multi-Racial

Native American

Pacific Islander

Prefer Not to Answer

Other (please specify)

Thank you for taking the time to fill out this Referral. Please note, completing this referral form does not guarantee consultation services. Caregiver Connections provides consultation directly to childcare providers and all services are voluntary. If you have any questions, please contact our intake coordinator at 217-592-0389.

Caregiver Connections
Early Childhood Mental Health Consultation