ECMH Parent/Guardian Referral ECMH Referral Form (Parent) 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 CountyName of Child: * RequiredChild Date of Birth: - must be mm/dd/yyyy format * Required Does your child receive Child Care Scholarship from the state? (formerly called Child Care Subsidy, Child Care Voucher, or Purchase of Care) * Required Yes No What concerns do you have? How can Project ACT help? * RequiredDoes your child 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 child care program to provide services? * Required Yes No What services are provided to your child in the child care program? (select all that apply) Speech & Language Therapy Occupational Therapy Special Instruction Behavior Intervention Physical Therapy Nursing Services Parent/Legal Guardian Name * RequiredPhone Number * RequiredParent/Legal Guardian Email * Required What is your child's ethnicity?Black/African AmericanCaucasianHispanic/LatinoAsianMultiracialOtherParent/Child Address * 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 Child Care Program * RequiredTeacher/Family Child Care Provider's Name * RequiredDirector's name (if applicable)Email of Director/Family Child Care Provider * Required Section BreakName of individual completing the form: * Required First Last Are you the parent/guardian? * Required Yes No Relationship to parent/guardian:Models 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.