Request Consultation

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Request Consultation

First Name of Person Referring *

Last Name of Person Referring *

Phone Number of Person Referring *

What is the best time of day to contact you? *

Email Address of Person Referring *

Primary Language of Person Referring *

Other Language

Interpreter Needed? *

Role of Person Referring *

Director/Administrator

Parent/Family Member

Teacher/Practitioner

Child Care Provider

Mental Health Therapist/Clinician

Service Provider (Home Visitor, Birth to 3 Professional, Special Education Provider etc.)

Primary Care Physician

Licensing Specialist

Training and/or Technical Assistance Provider

Community Member

Other

Is this request for consultation at a DCF licensed facility? *

If yes, please provide the site’s Provider Number and Location Number. How to find these numbers.

Program type *

Please choose from the following:

Provider Number

Location Number:

Approximately how many children 5 and under do you serve?

For which agency do you work?

Other Role of Person Referring

Address

Apt, suite, etc.

Country

City

State

Zip code

County *

What type of consultation are you looking to receive or learn more about? (check all that apply) *

Child/Family

Classroom/Teacher

Programmatic

Community

Not Sure

Consultation Types

Child/Family: Consultant collaborates with families and caregivers and staff to understand and respond effectively to a child’s mental health needs. Assists caregivers to understand and effectively respond to the mental health needs of a family. Consults to families, other caregivers and staff about a particular child or family.

Classroom/Teacher: Consultant explores how the classroom supports all children’s social emotional development. Collaborates with parents and caregivers to assess relationships, routines, and practices that impact the classroom or home climate.

Programmatic: Consultant assesses a program’s systems, policies, procedures, professional development, philosophy and mission as they relate to supporting mental health of young children and their families.

Community: Assists organizations, systems, and communities to improve social, emotional, and behavioral outcomes through partnership, collaboration, and coordination. Activities include: providing outreach and engagement related to IMH, IECMHC, and other related topics; linking families, groups, and organizations; supporting cultural awareness, responsiveness, and celebration; facilitating training and education for families and the broader community; tracking community needs to inform larger system improvements; and, connecting families to events and opportunities for recreation and community participation.

Consultation Information

Referral Reason (Check all that apply):

Physical Aggression towards others

Hurting Self

Disruptive and/or Tantrums

Trouble Following Directions

Running Away from Adults

Unsafe Behaviors

Withdrawn/Prefers to be Alone

Trouble Interacting with Others (play, engaging in classroom activities)

Sleeping/Feeding Issues

Inability/Difficulty to Sooth

Flat Affect/Non-Engagement

Concerns about child’s emotions

Recent Loss/Grief

History of Trauma or Adversity

Challenging Home Environment/Family Stress

Strained Provider-Family Relationship

Developmental Delay

Odd Behaviors

Does Not Communicate

Other

Please briefly describe the reason for this referral:

Are you the child’s legal parent/guardian?

Has this referral been discussed with the child's parent/guardian?

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Email Address

Child’s First Name

Child’s Last Name

Date of Birth

Child’s Gender (select all that apply)

Female

Male

Gender Non-Conforming/Transgender

Non-Binary

Other

Prefer Not to Report

Don’t Know

Child’s Race/Ethnicity (select all that apply)

American Indian

Alaskan Native

Asian

Black or African American

Latino/Hispanic

Native Hawaiian

Pacific Islander

Two or More Races

Caucasian

Other

Prefer Not to Report

Don’t Know

Child’s Primary Language

Child’s age

Is this child in child care?

What type of care is the child receiving?

Child Care Center

Family Child Care/In-Home Provider

School

Not Sure

Other

Name of Child Care (if applicable):

Is the child at risk of being removed from their child care setting?

Referral Reason (Check all that apply):

Classroom Management/Reduce Challenging Behaviors

Feeling Stressed or Overwhelmed

Support Needed Connecting to Adult Wellbeing/Self-Care/Mental Health Resources

Support Needed with Individual Child Social-Emotional Development

Support Needed with Class Social and Emotional Development

Support Needed with Staff to Director Relationships

Support Needed with Staff to Staff Relationships

Support Needed with Staff to Family Relationships

Support with Diversity and Cultural Considerations

Outreach/Family Engagement

Desire to Strengthen Provider-Family Relationship

Please briefly describe the reason for this referral:*

Are you the teacher reaching out about your own classroom?

Is the classroom teacher aware of the referral?

Name of Child Care (if applicable):

Please indicate the type of program

Referral Reason (Check all that apply):

Staff Feeling Stressed and Overwhelmed

Desire to Strengthen Workplace Relationships

Strained Provider-Family Relationships

Well-being/Resilience

Lead Reflective Sessions

Classroom/Setting Climate

Parent Training/Workshop

Professional Development for Staff

What type of professional development does your staff need?

Early Childhood Mental Health

Social-Emotional Development

ACES, Toxic Stress, & Resilience Building

Trauma-Informed ECE Settings

Family Engagement

Creating Inclusive Classrooms

Diversity, Equity and Inclusion

Other Training/Workshop

Please briefly describe the reason for this referral:

Are you an administrator or a staff member at the program you are referring to?

Is the program aware of the referral?

Please indicate the type of program

Name of Child Care (if applicable)

Referral Reason (Check all that apply):

Staff Feeling Stressed and Overwhelmed

Desire to Strengthen Workplace Relationships

Strained Provider-Family Relationships

Well-being/Resilience

Lead Reflective Sessions

Classroom/Setting Climate

Parent Training/Workshop

Professional Development for Staff

What type of professional development does your staff need?

Early Childhood Mental Health

iSocial-Emotional Development

ACES, Toxic Stress, & Resilience Building

Trauma-Informed ECE Settings

Family Engagement

Creating Inclusive Classrooms

Diversity, Equity and Inclusion

Other Training/Workshop

Please briefly describe the reason for this referral:

Is this referral for a specific child? *

Name of Community:

How did you hear about Healthy Minds Healthy Children *

Through a friend

Google/Search Engine

Social Media

Conference

Employer

Service Provider

Medical Professional

Training/Technical Assistance Provider

Licensing

Other

(Infant and Early Childhood Mental Health Consultation (IECMHC))

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