and the Maine Department of Health and Human Services, Office of Child and Family Services, Early Childhood Division, Children's Behavioral Health
| Primary Site Contact Name: | |
| _______________________________________ | Phone: __________________________________ |
| Position: | Fax: ____________________________________ |
| Email: __________________________________ | |
Director/Owner/s Contact Name: |
|
| _______________________________________ | Phone: __________________________________ |
| Position: | Fax: ____________________________________ |
| _______________________________________ | Email: __________________________________ |
| Do you have multiple sites:___ Yes ___ No | Agency/Organization (if applicable): ____________________________ |
| Main Address: | Site Address: |
| City/Town: _______________________________ | City/Town: _______________________________ |
| County: _________________________________ | County: _________________________________ |
| ZIP Code: _______________________________ | ZIP Code: _______________________________ |
| Phone: __________________________________ | Phone: __________________________________ |
| Fax: ____________________________________ | Fax: ____________________________________ |
| Program/School Name: _____________________ | School Administrator: _______________________ |
| School District (if applicable): ____________________________ |
Name of classroom/group (if applicable): ____________________________ |
|
□ Licensed Child Care Center |
□ Head Start/Early 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): | |
| □ Infant | □ Toddler | □ Preschool | □ School-age |
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 Consultation |
| □ Individual Child Consultation |
What do you hope to gain from this TA? (please use additional paper, if necessary)
What resources are already in place to support your efforts toward these goals?
_______________________________________________________________________
_______________________________________________________________________
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?
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? _____________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________________________
_______________________________
Director/Owner/School Administrator signature
Date of request
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: 11/09/2008
| For Office Use ONLY: Date Rec’d: ________Reviewed by: ________ Assigned to: ________TA #:________ |