IECHM Consent Forms - Abilities Network Project ACT

Important Notice Before You Begin

This form is a required part of the referral process and must be completed in full before we can move forward. Please read the following carefully:

• The form is detailed and must be completed in one sitting. There is no option to save and return later.
• You will need to upload documents as part of this form. This includes a copy of the child’s IEP or IFSP, if applicable.
• If the child is not your biological or legally adopted child, you will also need to upload documentation showing proof of legal guardianship.

We know it takes time, and we truly appreciate your effort. Completing everything now helps us avoid delays and support your child more effectively.

ECMH Parent Paperwork

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Infant and Early Childhood Mental Health Services

Your Name(Required)

First Last

Phone(Required)

Email for Notifications(Required)

Perferred method of contact(Required)

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Your Child's Name(Required)

First Last

Length of time for child at current address(Required)

Models of Service

Click here → Models of Service

Consent to Receive Services

Abilities Network, Inc. is a charitable nonprofit organization that assists children with behavioral and/or developmental challenges. To provide education, training, and advocacy services to children, adults, and families, Project ACT, a department of Abilities Network, requires that all parents or legal guardians of minor children served by Project ACT read and sign this Consent for Services Form.

I affirm as follows:(Required)

I am the parent of the child, and I have full custodial rights over my minor child.

I am the parent of the child, and I have shared custodial rights over my minor child.

I am the guardian of the child, and I have full custodial rights over my minor child.

I am the guardian of the child, and I have shared custodial rights over my minor child.

If you are not a natural/adoptive parent with full custodial rights over your minor child/ward, you must present Abilities Network with proof of guardianship in the form of a court order, letter from a social worker or adoption papers before Abilities Network can provide services to your minor child. This documentation must be uploaded here and will be maintained in Abilities Network’s files.

Max. file size: 63 MB.

Shared Custodial Information

Name of Other Parent/Guardian

First Last

Address

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

Relationship to Child

Consent to Release/Recieve Information

In order to provide the best services possible to your child, Project ACT request’s consent to contact any outside agencies that may be currently working with your child in order to coordinate programing. Please indicate any outside agencies or individuals (Infants & Toddlers, Child Find, Doctors, etc.) with whom you would like Project ACT to be able to exchange information regarding your child. This permission to release/receive information to/from outside entities is NOT required by Project ACT and may be left blank. This authorization may be revoked at any time.

I would like to give consent for exchanging of information for my child.(Required)

Yes

Agency Name

Name

First Last

Address

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

Email Address

Email Address Confirm Email Address

Phone Number

Permission is given to

Send information to

Recieve information from

Verbally discuss

Information to Be Exchanged

Name and Contact Information

Assessment Information

Progress Notes

Clinician' Report

Reason for Referral

Medical Records

Other

Reason this information is being shared

Do you need to add a second agency?

Yes

Agency Name

Name

First Last

Address

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

Email Address

Email Address Confirm Email Address

Phone Number

Permission is given to

Send information to

Recieve information from

Verbally discuss

Information to Be Exchanged

Name and Contact Information

Assessment Information

Progress Notes

Clinician' Report

Reason for Referral

Medical Records

Other

Reason this information is being shared

Do you need to add a third agency?

Yes

Agency Name

Name

First Last

Address

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

Email Address

Email Address Confirm Email Address

Phone Number

Permission is given to

Send information to

Recieve information from

Verbally discuss

Information to Be Exchanged

Name and Contact Information

Assessment Information

Progress Notes

Clinician' Report

Reason for Referral

Medical Records

Other

Reason this information is being shared

Consent Continued

Family Profile

Child's Age in Months(Required)

Gender Identity(Required)

Was your child born permaturely(Required)

Yes

If so, how many weeks premature?

Child's Racial Identity(Required)

Parent Marital Status(Required)

Who lives in the home? Please list any siblings or extended family and ages of any children.(Required)

Primary Language Spoken at Home(Required)

English

Spanish

Other

Does your child have Medical Assistance(Required)

Yes

How long has your child been in the current center?(Required)

How many classrooms has your child been in?(Required)

Days of the Week Your Child Attends Child Care(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Approximate Time of Drop Off

Approximate Time of Pick Up

Has your child experienced any of the following? (check all that apply)(Required)

Has the child been in any other Child Care Center(s) or Family Child Care settings?(Required)

How many other child care placements(Required)

Is your child currently at risk of expulsion(Required)

Yes

Has your child ever been asked to leave a child care program?(Required)

Yes

If yes, please explain

Have you ever contacted any resources for help with your child?(Required)

Psychologist

Therapist or Counselor

Child Find or Special Education Services

Infants and Toddlers

Pediatrician

Behavioral Specialist

None of the Above

If yes, please explain

Please list any diagnosed disabilities or mental health conditions your child has.(Required)

If your child has an IEP (Individualized Education Program) or an IFSP (Individualized Family Service Plan), please upload it here.

Max. file size: 63 MB.

Is the child receiving any type of therapy (speech, OT, PT, etc.)?(Required)

If yes, please explain type, how often, and where services are provided.

Is the child or family receiving any of the following services? (check all that apply)

Supplemental Nutrition Assistance Program (SNAP)

Temporary Assistance for Needy Families (TANF)

Women, Infants and Children (WIC)

Maryland Children's Health Program (MCHP)

Child Care Scholarship

General Medical Information

Any concerns about the child’s motor skills (i.e. walking, sitting, crawling)?(Required)

Yes

Does the child have feeding problems?(Required)

Yes

Does the child have any medical problems (i.e. allergies, asthma, seizure)?(Required)

Yes

Has eye sight been checked?(Required)

Yes

Has hearing been checked?(Required)

Yes

Does your child have a pediatrician?(Required)

Yes

Does the child put 2-3 words together?(Required)

Yes

If your child is on any medication please list and note it's usages

How does the child communicate (point, words, babble, sign language)?(Required)

Does the child understand simple directions? (e.g. “Put that down”, “Get your coat”)(Required)

Yes

I certify that the information provided is true and accurate to the best of my knowledge.(Required)

84335