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 our Parent/Guardian Intake Referral. By doing so, it will us help provide the services you are requesting.

Caregiver Connections
Early Childhood Mental Health Consultation