Special Needs Childcare Program Consultation Request Special Needs Consultation Request "*" indicates required fields Owner/director name* First Last Email address* Daytime phone number*Preferred method of follow-upPhoneEmailVirtual meetingChild care program and classroom/teacher name (if applicable)How many children are receiving services in your program? (IEP, IFSP, Speech, OT, PT)List any challenging behaviors in the classroom, if any. (eloping, biting, tantrums, physical aggression)What type of support are you seeking? Consultation (8-12 weeks) Coaching, team meetings, or training?Do you prefer virtual training or in person workshops at our office or your child care program?If this request is regarding a specific child enrolled or soon to be enrolled in your program, please complete the following fields.Child's ageInfant/toddler3-4 years old5 years old6-9 years old10-12 years old13 years and olderHas the child been suspended or expelled from a previous care setting? Yes No Unknown Is the child currently at risk of suspension or expulsion from your program? Yes No Unknown N/A – not yet enrolled To your knowledge, is the child receiving services? Yes No Unknown How long has the child been enrolled in your program?Not yet enrolledLess than 3 months6-12 months1-2 years3-5 yearsLonger than 5 yearsCAPTCHANameThis field is for validation purposes and should be left unchanged.
