Special Needs Childcare Program Consultation Request Special Needs Consultation Request "*" indicates required fields FacebookThis field is for validation purposes and should be left unchanged.Owner/director name* First Last Email address* Daytime phone number*Program zip code*Preferred method of follow-upPhoneEmailVirtual meetingChild care program and classroom/teacher name (if applicable)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. Do not include the child’s last name or date of birth.Child's first nameChild's age in yearsLess than 1 year old1 year old2 years old3 years old4 years old5 years old6 years old7 years old8 years old9 years old10 years old11 years old12 years old13 years old14 years old15 years old16 years or olderChild's diagnosis (all that apply) Autism Spectrum Disorder Down Syndrome Aphasia or Dysphasia Auditory Processing Disorder Visual Processing Disorder Cerebral Palsy ADHD Cystic Fibrosis Multiple Sclerosis Muscular Dystrophy Epilepsy Fetal Alcohol Syndrome Disorder Developmental Delay Waiting to be evaluated None If no diagnosis, provider or family suspects (please describe/explain):Has 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 How long has the child been enrolled in your program?Not yet enrolledLess than 3 months6-12 months1-2 years3-5 yearsLonger than 5 yearsUntitled
