Purpose

This Agreement outlines the expectations, responsibilities, and shared commitment between Project ACT Inclusion Specialists (referred to herein as “the Consultant”) and the Child Care Program (referred to herein as “the Program”) participating in Infant and Early Childhood Mental Health (IECMH) consultation services. These services aim to strengthen the social-emotional well-being of children, improve classroom environments, and support educator wellness through reflective, trauma-informed practices.

Scope of Services

The Consultant will provide IECMH consultation and supports tailored to the program and child/family needs. Services may include:

• Observations of the physical and emotional classroom environment
• Collaborative meetings with teaching staff, administrators, and caregivers
• Strategies to support a specific child’s social-emotional development
• Classroom-level strategies to improve behavior guidance and engagement
• Resources to enhance teacher wellness and resilience
• Facilitation of referrals to additional services (e.g., mental health, early intervention) with caregiver consent

Name(Required)

First Last

Program Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Required Documents Reviewed(Required)

Models of Service

What We Do/Don't Do Overview

Assessment Expectations(Required)

I agree support staff and parents/guardians in completing assessments.

The following screening tools will be distributed and are essential to initiating consultation:
For Staff (prior to first observation):

• DECA (Devereux Early Childhood Assessment) Checklist

For Parents/Guardians (please encourage online completion):
• DECA (Parent Form)
• Ages and Stages Questionnaire (ASQ)
• Ages and Stages: Social-Emotional (ASQ:SE)

Assessments must be returned to the Inclusion Specialist prior to or during the first classroom observation.

Timely Communication(Required)

I agree to timely communication.

• Respond to Consultant communication within 2 business days.
• Notify the Consultant in advance of closures, staff changes, or conflicts
• Inform the Consultant of any changes to classroom assignments or teaching staff.
• Inform the Consultant of any changes to the child’s assigned classroom.
o If there is a change in the child’s assigned classroom, before consultation can continue, a collaborative meeting must be scheduled with the new teachers, director and Inclusion Specialist to ensure a smooth transition.

Facilitated Access(Required)

I agree to the facilitating access.

• Allow access to classrooms, playgrounds, and shared areas for observation.
• Provide a private, confidential meeting space for consultations with staff or families.

Staff Engagement(Required)

I agree to support staff engagement.

• Allocate time for staff to participate in meetings during regular working hours.
• Encourage honest, reflective participation in the consultation process.
• Promote a culture of collaboration and openness to learning.

Implementation of Recommendations(Required)

I agree to support staff in implementing recommendations.

• Make a good-faith effort to implement strategies or tools recommended by the Consultant.
• Communicate outcomes, successes, or barriers to help guide ongoing support.

Confidentiality and Consent(Required)

I agree to the privacy policy.

• Comply with confidentiality laws and program policies.
• Obtain written caregiver consent before any child-specific consultation or data-sharing.
• Protect sensitive information and respect family privacy.

Mutual Commitment to Equity and Inclusion

By participating in Project ACT, I agree to treat staff with respect regardless of their identity.

Both parties commit to creating safe, supportive environments for all children, families, and staff. This includes valuing identities and continuously working to reduce barriers to mental health and wellness supports in early childhood settings.

Consultant Responsibilities(Required)

I understand the role of the consultant.

The Consultant agrees to:
• Maintain professional and timely communication with Program staff
• Schedule site visits and meetings in collaboration with Program leadership
• Use evidence-informed and developmentally appropriate strategies
• Respect the culture, routines, and values of each program and family served
• Protect confidentiality and secure all necessary consents before sharing or documenting child-specific information
• Provide guidance aligned with the Pyramid Model and trauma-informed approaches

Termination of Services

I understand services can be terminated at any time and the process for termination by child care program or Consultant.

This agreement may be terminated at any time by either party with written notice.
The Consultant may initiate discontinuation of services in the following cases:
• Failure to respond to communication on an ongoing basis
• Inadequate access to classrooms or staff for observation or meetings
• Ongoing refusal to engage in or implement agreed-upon supports
• Failure to return essential paperwork or obtain consent
Termination Process
1. Consultant provides written notice outlining the concern(s)
2. Program is given an opportunity to discuss and address issues
3. If concerns remain unresolved, a final notice of service termination will be issued

By signing below, I am confirming my understanding and commitment to the terms of this partnership.(Required)

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