Center for Community Inclusion and Disability Studies
Maine’s University Center for Excellence in Developmental Disabilities Education, Research, and Service

and the Maine Department of Health and Human Services, Office of Child and Family Services, Early Childhood Division

Child Care Plus ME Request for Technical Assistance

Program/Provider Information:

Primary contact name:
 		 Address:
 
Position:
 
 
Agency/Organization (if applicable):
 		 City/Town:
 
  Zip Code:
 
Program/School name:
 		 Phone:
 
School District (if applicable):
 		 Fax:
 
Name of classroom/group (if applicable):
 		 E-mail:
 
   

Type of Program (please check only one):

□ Licensed Child Care Center

 □ Head Start
□ Licensed Preschool/Nursery School □ Combined Head Start/Child Care
□ Licensed Family Child Care Home □ Recreation Program
□ Legal/Unregulated Child Care □ Public School
□ Other (please specify):


Ages that the program/school serves (please check all that apply):

□ Infant □ Toddler □ Preschool □ School-age


Technical Assistance Planning

Have you discussed this request with a CCIDS staff member?       □ Yes           □ No


If “Yes,” with whom?____________________________________________________________________

 

Indicate the primary type of assistance you are requesting (please check only one):

□  Information & Resources □ Program/Administrative Consultation
□ Individual Child Consultation  

Technical Assistance/Consultation Goals:

What do you hope to gain from this TA? (please use additional paper, if necessary)

1.

2.

3.

What resources are already in place to support your efforts toward these goals?

 

Are there any other agencies/organizations currently involved with your program?
 □ Yes    □ No

If “Yes,” which?

Individual Child Consultation Information

For child-specific consultations, please notify the parent(s) or legal guardian of your request for Technical Assistance. Please make sure a CCIDS Consent for Release of Information form is signed by the parent(s) or legal guardian and returned with this request. If requesting a TA for multiple children, please complete the first page of this form only once and the entire second page for each individual child.

Child’s Initials:

Child’s Date of Birth:

Why are you requesting a consultation for this child?

 

 

Signature Authorizing this Request (Please note, this TA request must be signed.)

 

_______________________________________________      _______________________________
Director/Owner/School Administrator signature                               Date of request

Return completed TA Request form to:

University of Maine
Center for Community Inclusion & Disability Studies, UCEDD
48 Tandberg Trail, Windham, ME 04062
Phone (V/TTY): 207/892-0455
Toll Free (V/TTY): 866/230-4520
Fax: 207/892-2330
E-mail: ccidsmail@umit.maine.edu
Web site: www.ccids.umaine.edu

Updated: 04/02/3007

For Office Use ONLY: Date Rec’d: ________Reviewed by: ________ Assigned to: ________TA #:________

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