FY 2023 Consultant Survey - Pre-service Referral

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* 1. Please choose your SDA or County

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* 2. Date:

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* 3. Program Contact Information:

Name of Program:

Address:

City:

Illinois, Zip Code:

Phone Number:

Email:

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* 4. Type of Child Care:

Center

Family Care Home

Family Group Home

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* 5. Can you tell us how you became aware of our Mental Health Consultation Services?

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

Yes

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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)

Yes

Not Applicable

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* 8. If you are referring a child for our Mental Health Consultation services, is the child at risk for no longer remaining in your program?

Yes

Not Applicable

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* 9. If you are referring a child for our services, is the child or their family involved with DCFS? If yes, then please provide the DCFS Caseworker's name and contact information:

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* 10. Contact Information (Person Completing This Form)

Name:

Position:

Email:

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

Please list other concerns

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* 12. Briefly describe your concern or need:

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

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

Asian

Black/African

Caucasian

Hispanic/Latino

Multi-Racial

Native American

Pacific Islander

Prefer Not to Answer

Other (please specify)

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

Getting an outside opinion about a child or situation in my program

Improvement in a child's behavior

Guidance in dealing with a difficult situation in my program

Getting information about and connection to community resources/services

Ideas for working with a child or group of children

Help to better understand a child's or children's needs, development, behavior

Support for me and/or staff in our work

Help working with a family of a child in my/our care

Guidance with a decision about whether or not a child can remain in this program

Helping our staff work together more effectively as a team with the child(ren)

Other or specific training requested

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

Yes

If yes, is there a particular topic you are interested in?

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

Yes

If yes, who or what type of service?

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