FY2024 - Caregiver Connections Pre-Service Survey

This form should be filled out by either the child care center director (in collaboration with teaching staff, if applicable) or the owner for the Family Child Care program.

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* 1. Are you seeking consultation services in a language other than English?

Yes

If yes, please contact 217-629-5165 for our interpreter services to complete the intake process.

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* 2. Date:

Date / Time

Date

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* 3. Please indicated which SDA (Service Delivery Area) you are located:

SDA 01 - Boone, Jo Daviess, Stephenson, and Winnebago Counties

SDA 02 - Carroll, DeKalb, Lee, McHenry, Ogle, and Whiteside Counties

SDA 03 - Lake County

SDA 04 - DuPage and Kane Counties

SDA 05 - Grundy, Kankakee, Kendall, and Will Counties

SDA 06 -Cook - North Side/Uptown Area

SDA 06 - Cook - North Suburban Area

SDA 06 - Cook - Central/West Side Area

SDA 06 - Cook - South Side Area

SDA 06 - Cook - South Suburban Area

SDA 07 - Henderson, Henry, Knox, McDonough, Mercer, Rock Island, and Warren Counties

SDA 08 - Bureau, Fulton, LaSalle, Marshall, Peoria, Putnam, Stark, Tazewell, and Woodford Counties

SDA 09 -DeWitt, Ford, Livingston, and McLean Counties

SDA 10 - Champaign, Douglas, Iroquois, Macon, Piatt, and Vermilion Counties

SDA 11 - Clark, Coles, Cumberland, Edgar, Moultrie, and Shelby Counties

SDA 12 - Adams, Brown, Calhoun, Cass, Greene, Hancock, Jersey, Pike, and Schuyler Counties

SDA 13 - Christian, Logan, Macoupin, Mason, Menard, Montgomery, Morgan, Sangamon, and Scott Counties

SDA 14 - Bond, Clinton, Madison, Monroe, Randolph, St. Clair, and Washington Counties

SDA 15 - Clay, Crawford, Edwards, Effingham, Fayette, Jasper, Jefferson, Lawrence, Marion, Richland, Wabash, and Wayne Counties

SDA 16 - Alexander, Franklin, Gallatin, Hamilton, Hardin, Jackson, Johnson, Massac, Perry, Pope, Pulaski, Saline, Union, White, and Williamson Counties

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* 4. Program Contact Information:

Name of Program:

Your Name:

Address:

City:

Illinois, Zip Code:

Phone Number:

Email Address:

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* 5. Your role in the child care program:

Director

Assistant Director

Teacher

Assistant Teacher

Family Child Care

Group Family Child Care

Other (please specify)

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* 6. Type of Child Care:

Child Care Center

Family Child Care Home

Family Child Group Home

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* 7. Do you or your program accept financial assistance?

Yes

If yes, please specify type of financial assistance (Examples: CCAP, DCFS, DHS, ISBE - Preschool for All, Preschool for All Expansion, Prevention Initiative)

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* 8. What type of consultation services is your program seeking?

Program Specific - Program specific consultation is focused on the child care center/program as a whole. The purpose of this consultation is to support the whole center/program by building their capacity to understand and meet the environmental, behavioral, and social-emotional needs of their center/program.

Classroom/Provider Specific - Classroom/Provider specific consultation is focused on one classroom to build the capacity of the child care providers to understand and meet the environmental, behavioral, and social-emotional need of their learning environment.

Child Specific - Child specific consultation is focused on one child, to support their emotional, social, and behavioral needs. The goal of this consultation is to build the capacity of the child care provider to meet the needs of that child. Child Specific consultation is also intended to support a partnership between families and the child care provider to support the child's identified needs.

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* 9. Briefly describe why you are seeking Consultation Services (please include your thoughts on things such as: your goal for reaching out, expectation of consultation, what you hope to gain from working with a consultant etc.)

*If you are seeking Child Specific consultation, please complete the questions below. If not, indicate N/A (not applicable.)

*If you are referring more than one child for consultation services, each child will require their own pre-service survey.

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* 10. If you are seeking a child specific consultation, does the child's family receive a child care subsidy? (CCAP)

Yes

N/A

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* 11. Is this child at risk of no longer remaining in your program?

Yes

N/A

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* 12. Is this child involved in a DCFS case?

Yes

N/A

If yes, please provider the caseworker's name and contact information:

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* 13. Is the child currently receiving therapeutic services or is involved with Early Intervention or the local school district for services (IFSP, IEP?) If yes, please explain:

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* 14. If you are referring a child, what is the age of the child you are contacting us about?

Infant (less than a year old)

If the child is over the age of 5, please indicate the child's age

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* 15. If you are referring a child, what is the child's gender?

Male

Female

Prefer Not to Answer

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* 16. If you are referring a child, please select the race the child identifies as:

African American

Asian

Caucasian

Hispanic/Latino

Native American

Pacific Islander

Multi-Racial

Prefer Not to Answer

Unknown

Other (please specify)

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* 17. How did you hear about Caregiver Connections consultation services?

Caregiver Connections Website

Governor's Office of Early Childhood Development (GOECD) Website/Marketing Campaign

Child Care Resource & Referral Agency (CCR&R)

Another Community Service Provider - Referral or Presentation

Attended a Caregiver Connections training or have had consultation services previously

Referred by another child care provider or family child care association/group

Other (please specify)