ECMH – Child Care Provider Referral ECMH Referral Form (Provider) Project ACT can only provide consultation services in Baltimore, Harford and Cecil Counties. Click here to locate services in other areas of Maryland. In what county is your child care program located? Project ACT can only provide this service in the jurisdictions below. * Required Baltimore County Harford County Cecil County What is your preferred service delivery method? (Project ACT cannot guarantee a specific delivery model at this time but will work to meet each program's needs.) * Required In-person - consultant comes to your program, utilizes PPE, and maintains social distance Virtual - Zoom, telephone, and email only Hybrid - in-person visits only when necessary, other visits/meetings done virtually Project ACT requires that all adults wear masks when participating in in-person consultation services. * Required I understand the masking requirement for in-person services. Does your program have a written policy regarding COVID-19 vaccination and/or testing requirements for in-person visitors? * Required Yes No Please upload a copy of your program's COVID-19 vaccination and/or testing policy. * RequiredMax. file size: 63 MB.In order to reach more families and raise awareness of the importance of social, emotional, and behavioral development, Project ACT would like to conduct one resource session at your program. Resource sessions will consist of a table with resources and giveaways for families, lasting approximately 1 hour (utilizing appropriate health & safety measures, at a time/date mutually agreed upon). I'm happy to host a resource session for families at my program. I'd like to learn more about the resource sessions. Do 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: * Required Child Date of Birth: - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Does the child receive Child Care Scholarship from the state? (formerly called Child Care Subsidy, Child Care Voucher, or Purchase of Care) * Required Yes No How 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: * Required Phone 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 * Required Address 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 * Required Director (if applicable) Email of Director/Family Child Care Provider * Required License Number * Required How many children are enrolled in the program? * RequiredHow many classrooms are in the program? * RequiredHow many children are in the identified child's classroom? * 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? * Required MSDE NAEYC No 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? * Required Yes No Models of Service Have you read the models of service? * Required I 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.