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* 2. For Consultant Use: Provider Code and Consultation ID

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* 3. Date:

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* 4. Program Contact Information:

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* 5. Type of Child Care:

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* 6. Do you or your program accept a child care subsidy? (CCAP)

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* 7. If you are referring a child for our Mental Health Consultation Services, does the child's family receive a child care subsidy? (CCAP)

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* 8. Is this child at risk for no longer remaining in your program? 

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* 9. Contact Information (Person Completing This Form)

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* 10. Please choose the reason(s) you are requesting services, then check how concerned you are about this:

  N/A 1 - A little 2 3 - Somewhat 4 5 - Extremely concerned
Support and helping me/staff in working with a child or children
Support and helping me/staff in working with parents or family
Support and helping me/staff with a transition plan for a child or children
Support and helping in seeking outside programs or resources
Other areas/needs for support/help
Other concerns

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* 11. Briefly describe your concern or need:

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

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* 13. What are your expectations of our mental health consultation?

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* 14. Are you contacting us to provide you or your program with Gateway Registry Approved Training?

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* 15. Is there another service provider or person you can call upon for this kind of help?

Thank you for taking the time to fill out our Consultation Survey. By doing so, it will us help provide the services you are requesting.

Caregiver Connections
Early Childhood Mental Health Consultation

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