FY2025 - Caregiver Connections Request for Services - Classroom Specific

Classroom/provider specific consultation is focused on one classroom to build the capacity of the childcare providers to understand and meet the environmental, behavioral, and social-emotional needs of their learning environment.

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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 classroom/provider specific referral (select one)

Positive Behavior Support

Transitions

Peer Relational Development

Adult/Child Relationships

Social/Emotional Environment/Learning

Classroom Management

Provider Relations/Support

Enhance Culture/DEIB Environment

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* 11. Name of the primary provider or lead teacher/provider in the classroom who will receive the consultation services:

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* 12. Complete the following related to the level of challenging behaviors in the classroom:

Low (Example: One or more children cannot participate in at least one activity a week due to challenging behaviors.)

Medium (Example: Two or more children cannot participate in at least one activity a week due to challenging behaviors OR There is a concern that at least one child has to be removed from the classroom/group environment per week.)

High (Example: One or more children cannot participate in at least one activity daily due to challenging behaviors. OR There is a concern that at least one child either has to be sent home due to challenging behaviors or requires a reduced childcare week.)