Special Needs 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 name (if applicable) 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 yearsCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
