FY2025 - Caregiver Connections Request for Services

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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

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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

Family, Friends, or Neighbor Child Care Provider

Another Community Service Provider

Other (please specify)

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

Yes

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* 7. If yes, please select all types of financial assistance that apply:

CCAP

DCFS

DHS

ISBE

Preschool for All

Preschool for All Expansion

Prevention Initiative

Other - Please Indicate:

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* 8. Type of Child Care:

Child Care Center

Family Child Care Home

Family Child Care Group Home

Friends, Family, or Neighbor Care

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* 9. 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)

Attended a Caregiver Connections training or have had consultation services previously

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

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* 10. Primary Reason for a child specific referral (select one)

Positive Behavior Guidance

Anxiety/Trauma Child

Peer Relational Development

Adult/Child Relationships

Transitions

Social/Emotional Environment/Learning

Provider/Family Relationships/Support

Enhance Culture/DEIB Environment

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* 11. Name of the primary provider who will receive the consultation services:

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* 12. How would you rate the level of challenging behaviors exhibited by the child? (Please select one option below using the scenarios as examples.):

Low (Example: The child cannot participate in at least one activity a week due to challenging behaviors.)

Medium (Example: The child cannot participate in at least one activity daily due to challenging behaviors or is removed from the classroom/environment.)

High (Example: There is a concern that the child either has to be sent home due to challenging behaviors or requires a reduced childcare week.)

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* 13. Complete the following related to the level of challenging behaviors exhibited by the child:

The child cannot participate in at least one activity a week due to challenging behaviors.

The child cannot participate in at least one activity daily due to challenging behaviors.

There is a concern that the child either has to be sent home due to challenging behaviors or requires a reduced childcare week.

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* 14. Does the child's family receive a child care subsidy? (CCAP)

Yes

Unknown

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

Yes

Unknown

If yes, please provider the caseworker's name, phone number, and email address:

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* 16. Is the child currently receiving any of the following services (Check all that apply)

IFSP-Early Intervention

IEP-Local School District Services

Other Developmental Services

Mental Health or Behavioral Services

The child is not receiving any of these services

Unknown

Other (please specify)

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* 17. 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

FY2025 - Caregiver Connections Request for Services - Child Specific

Question Title

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

Question Title

* 2. Date

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

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* 4. Program Contact Information:

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* 5. Your role in the child care program:

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

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* 7. If yes, please select all types of financial assistance that apply:

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* 8. Type of Child Care:

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

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* 10. Primary Reason for a child specific referral (select one)

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* 11. Name of the primary provider who will receive the consultation services:

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* 12. How would you rate the level of challenging behaviors exhibited by the child? (Please select one option below using the scenarios as examples.):

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* 13. Complete the following related to the level of challenging behaviors exhibited by the child:

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* 14. Does the child's family receive a child care subsidy? (CCAP)

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

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* 16. Is the child currently receiving any of the following services (Check all that apply)

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* 17. What is the age of the child you are contacting us about?

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* 18. What is the child's gender?

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* 19. What is the race the child/family identifies as: