ECMH Parent/Guardian Referral

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 *

Baltimore County
Harford County
Cecil County

Name of Child: *

Child Date of Birth: *

Does your child receive Child Care Scholarship from the state? (formerly called Child Care Subsidy, Child Care Voucher, or Purchase of Care) *

Yes
No

What concerns do you have? How can Project ACT help? *

Does your child have an IEP or IFSP? *

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? *

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 *

Phone Number *

Parent/Legal Guardian Email *

What is your child's ethnicity?

Parent/Child Address *

Street Address Address Line 2 City State ZIP Code

Please note: We are only able to provide services in Baltimore, Harford and Cecil County.

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Name of Child Care Program *

Address of Child Care Program *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number of Child Care Program *

Teacher/Family Child Care Provider's Name *

Director's name (if applicable)

Email of Director/Family Child Care Provider *

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Name of individual completing the form: *

First Last

Are you the parent/guardian? *

Yes
No

Relationship to parent/guardian:

Models of Service

Have you read the models of service? *

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.

ECMH Referral Form (Parent)

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Models of Service

Funders and Partners