Get Early Childhood Mental Health Consultation Program Request For ...

Filling out the Early Childhood Mental Health Consultation Program Request For Services online can be straightforward with the right guidance. This guide provides clear, step-by-step instructions to help you accurately complete each section of the form.

Follow the steps to complete the request form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date at the top of the form. This should be the date on which you are filling out the form.
3. Input the case ID assigned by the consultant in the designated field.
4. Fill in the child's name as it appears on official documents, followed by their date of birth.
5. Identify the primary reason for your request by selecting the appropriate option from the list provided.
6. Use the attachment area to further explain your concerns, providing specific details related to your request.
7. Indicate whether the child has an Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) by selecting 'Yes' or 'No'.
8. List any other agencies involved with the child in the specified area.
9. Respond to whether the child is at risk for expulsion from the program by selecting 'Yes' or 'No'.
10. Indicate if you have discussed your concerns with the child's parent(s) and summarize their understanding of the problem.
11. Complete the facility information section, including facility name, certificate number, director's name, facility type, address, phone, fax, email, county, STAR level, region, and whether the facility is currently receiving technical assistance (TA).
12. Provide Classroom Information for the referred child, including teacher names, education levels, classroom names, and the total number of children in the classroom.
13. Obtain the facility director's signature and include the date.
14. Classroom staff should complete the section regarding if a screening has been conducted for the child, and if so, list the tool/results.
15. Select the perceived primary reason for the child's behavior and provide any additional reasons if applicable.
16. List strategies that have been tried, along with the results for each strategy.
17. Rate your knowledge in specified areas by selecting the appropriate response.
18. Once all sections are completed, you can save changes, download, print, or share the form as needed.

Take the next step and fill out the Early Childhood Mental Health Consultation Program Request For Services online today.