Preschool Consultation Request Form - The Center for Early Childhood Connections

Please complete the following questions to apply for preschool MH consultation. Our staff will contact both the person completing this form and the program director regarding next steps and scheduling the first visit.

Contact Name*

Job title/role*

Contact Phone/ E-mail*

Program Name*

Age group served*

Program Director Name*

Program Director Phone/Email*

Program physical address*

Ages Served

Infants
Toddlers
Preschoolers
School Age

Approximate number of children enrolled*

Number of classrooms*

Number of classroom staff (teachers and assistants)*

Program hours*

Typical adult: child ratio*

How did they learn these methods?*

Are there gaps in the methods you currently use?*

What percentage of the staff has left their positions in the last year?*

Is your program receiving any coaching, resources or training on improving the environment or teaching strategies through QRIS or other programs? If so what are they?*

Do you have any written guidelines regarding communication and collaboration with families?*

How happy are you with the current practices around working with families?*

Does your program have a written discipline policy?*

How often does the program reduce a child's school hours or ask them to leave the program due to behavioral concerns?*

What kinds of consult are you requesting during the initial visit?

Programatic consult with an administrator
Classroom consult with a teacher (during classroom hours)
Consult with teacher/staff during non-program hours
Other/Not sure

Does your program have the space and time available for at least one hour of weekly consultation?*

Requested date of first visit*

Requested date of first visit

Requested time of first visit

Has your program ever worked with outside mental health or educational consultants? If so, please share anything that you think might be helpful for us to know about your experience.*

Do you have any comments or questions about how preschool MH consultation could help your program?