FY2026 - Caregiver Connections Request for Services Survey

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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. Today's 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

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 specify)

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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

FY2026 - Caregiver Connections Request for Services

Question Title

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

Question Title

* 2. Today's Date:

Question Title

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

Question Title

* 4. Program Contact Information:

Question Title

* 5. Your role in the child care program:

Question Title

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

Question Title

* 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. What type of service are you requesting?