IECMH – Child Care Provider Referral - Abilities Network Project ACT

Project ACT can only provide consultation services in Baltimore, Harford and Cecil Counties. Click here to locate services in other areas of Maryland.

In what county is your child care program located? Project ACT can only provide this service in the jurisdictions below. *

Baltimore County
Harford County
Cecil County

What is your preferred service delivery method? (Project ACT cannot guarantee a specific delivery model but will work to meet each program's needs.) *

In-person - consultant comes to your program for majority of service components
Hybrid - in-person visits only when necessary, other visits/meetings done virtually

Do you have parental permission to make this referral? *

Yes
No

Parental permission is required. If you would like to request Tier 1 services only, please fill out form at anprojectact.org/technical-assistance-request/

Parental permission is required to make a referral for a specific child. If you do not have parental permission, DO NOT submit this form. Please click here to submit a request for classroom support.

Name of Child: *

Child Date of Birth: *

Does the child receive Child Care Scholarship from the state? (formerly called Child Care Subsidy, Child Care Voucher, or Purchase of Care) *

Yes
No

How can Project ACT help? *

Does the child currently have an IEP or IFSP? *

Yes,IEP
Yes, IFSP
No

Does staff from Infants and Toddlers, Child Find or a Preschool Special Education program visit the program to provide services? *

Yes
No

What services are provided at the child care program? (select all that apply)

Speech & Language Therapy
Occupational Therapy
Special Instruction
Behavior Intervention
Physical Therapy
Nursing Services

Name of Parent/Guardian: *

Phone Number of Parent/Gaurdian *

Email of Parent/Gaurdian *

What is the child's ethnicity? *

Address of Child *

Street Address Address Line 2 City State ZIP Code

Please note: We are only able to provide services in Baltimore, Harford and Cecil County.

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All information is required to receive services. Missing or incorrect information will result in a delay of services. Services cannot be provided without working email addresses.

Name of Child Care Program *

Address of Child Care Program *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number of Program *

Teacher/Family Child Care Provider *

Email of Teacher/Family Child Care Provider *

Director (if applicable) *

Email of Director *

License Number *

How many children are enrolled in the program? *

How many classrooms are in the program? *

How many children are in the identified child's classroom? *

How many staff are in the program? *

How many staff are credentialed? *

Program's Maryland EXCELS Level *

Is the program accredited? (Please note, accreditation is a separate process from licensing.) *

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Name of individual completing the form: *

First Last

Have you made an Early Childhood Behavioral Consultation referral to Project ACT in the past year? *

Yes
No

Models of Service

Have you read the models of service? *

I have read and agree to the models of service

By agreeing, you indicate understanding of Project ACT’s model of service and are willing to be an active participant in the process of providing social/emotional support to your child. A lack or participation by Director (or Designee), Teacher(s), or Parent(s)/Guardian(s) can be cause for ending Project ACT Consultation.

ECMH Referral Form (Provider)

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Models of Service