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* 1. Contact Information 

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* 2. Are you a member of the Illinois Association for Infant Mental Health?

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* 3. Are you credentialed as an Infant/Early Childhood Mental Health professional through the Illinois Association for Infant Mental Health?

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* 4. Do you hold a minimum of a Master’s Degree in child development (specifically early childhood), social work, counseling, psychology, family and marriage therapy, psychiatry, or nursing?

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* 5. Do you have a minimum of 5 years of experience in areas related to infant and early childhood development and mental health?

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* 6. If you are licensed through the state of Illinois, what license do you possess?

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* 7. Reflective supervision/consultation is different from typical supervision or consultation. It requires a different approach than a traditional administrative approach to monitor compliance with requirements or expectations of a position or job and focuses more on the exploring the dynamics between children, families, and you as the professional.
Are you currently receiving reflective supervision/consultation in your work?

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* 8. Using the same description of reflective supervision/consultation in the previous question, have you provided reflective supervision/consultation in your work?

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* 9. Johnston and Brinamen (2006) have identified 10 elements that seem to be essential to the consultative stance. In the Illinois Model, the consultative stance as described is assumed. Have you provided consultation using this particular stance? 

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* 10. What counties/areas of Illinois are you available to provide infant/early childhood mental health consultation?  Please be specific.

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