ECMH – Child Care Provider Referral ECMH Referral Form (Provider) In what county is your child care program located? Project ACT can only provide this service in the jurisdictions below. For a listing of support available in other counties, please copy and paste this link into your browser: https://earlychildhood.marylandpublicschools.org/system/files/filedepot/24/ecmh_brochure_dec2014.pdf * RequiredBaltimore CountyHarford CountyCecil CountyDo you have parental permission to make this referral? * Required Yes No Parental permission is required. Parental permission is required to make a referral for a specific child. If you do not have parental permission, DO NOT submit this form. Please click here to submit a request for classroom support. Name of Child: * RequiredChild Date of Birth: - must be mm/dd/yyyy format * Required Does the child receive Child Care Scholarship from the state? (formerly called Child Care Subsidy, Child Care Voucher, or Purchase of Care) * RequiredYesNoHow can Project ACT help? * RequiredDoes the child currently have an IEP or IFSP? * Required Yes,IEP Yes, IFSP No Does staff from Infants and Toddlers, Child Find or a Preschool Special Education program visit the program to provide services? Yes No What services are provided at the child care program? (select all that apply) Speech & Language Therapy Occupational Therapy Special Instruction Behavior Intervention Physical Therapy Nursing Services Name of Parent/Guardian: * RequiredPhone Number of Parent/Gaurdian * RequiredEmail of Parent/Gaurdian * Required What is the child's ethnicity?Black/African AmericanCaucasianHispanic/LatinoAsianMultiracialOtherAddress of Child * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please note: We are only able to provide services in Baltimore, Harford and Cecil County. Section BreakName of Child Care Program * RequiredAddress of Child Care Program * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number of Program * RequiredTeacher/Family Child Care Provider * RequiredDirector (if applicable)Email of Director/Family Child Care Provider * Required License Number * RequiredHow many children are enrolled in the program? * RequiredHow many classrooms are in the program? * RequiredHow many staff are in the program? * RequiredHow many staff are credentialed? * RequiredProgram's Maryland EXCELS Level * RequiredNot PublishedLevel 1Level 2Level 3Level 4Level 5Is the program accredited? * RequiredMSDENAEYCNoOther Other Section BreakName of individual completing the form: * Required First Last Have you made an Early Childhood Behavioral Consultation referral to Project ACT in the past year? * RequiredYesNoModels of Service Have you read the models of service? * RequiredI have read and agree to the models of service By agreeing, you indicate understanding of Project ACT’s model of service and are willing to be an active participant in the process of providing social/emotional support to your child. A lack or participation by Director (or Designee), Teacher(s), or Parent(s)/Guardian(s) can be cause for ending Project ACT Consultation.