9.2019 Project WIN Intake - Prince George's Child Resource ...Thank you for your interest in Project...
Transcript of 9.2019 Project WIN Intake - Prince George's Child Resource ...Thank you for your interest in Project...
Project WIN (Wise Intervention Now)
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Early Childhood Mental Health Consultation Intake Form
Thank you for your interest in Project WIN! This program is designed to address the social and emotional needs of children from birth to five years of age who are currently enrolled in licensed child care settings throughout Prince
George’s County. Project WIN promotes positive social and emotional development, which is a key to school readiness. Early Childhood Mental Health (ECMH) professionals will collaborate with parents, child care providers, and community resources to address the concerns of behavior, developmental support, and/or expulsion from child
care by providing technical assistance, observing in the child care, identifying various ways to support child care providers/families, administering assessments, sharing recommendations for referral to other
community resources, and more! Please complete the intake form in its entirety, and submit the original form(s) to your assigned ECMH professional. If
you have any questions or concerns regarding the completion and/or content of this intake document, please contact Prince George’s Child Resource Center for support at 301.772.8420.
Date of initial request for services: _____________
Who made the initial request for services? Parent Child Care Program Provider Community Resource
How did the initial requestor learn about the Early Childhood Mental Health Consultation Program, Project WIN?
What prompted the request for services? Please describe in below:
Child Specific Information
Child’s Name:_____________________________________
Child’s Gender: ___________________________________
Child’s Date of Birth:___________________________
Child’s Ethnicity: ______________________________
Does your child speak or understand English? Yes No
Does your child speak or understand another language? Yes No
If yes, what language(s)?
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Was your child born prematurely? Yes No If yes, how many weeks premature? ___________________________
Does your child have any medical problems? Yes No
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If yes, please specify:
Asthma Allergies to Medicine(s) Seizure Seasonal Allergies
Other _______________________________________________________
Are there any additional medical concerns? Yes No
If yes, please describe below:
Is there any concern about your child’s gross motor and/or fine motor skills? Yes No
If yes, please describe: ___________________________________________________________
Does your child have feeding problems? Yes No
If yes, please describe: ___________________________________________________________
Does your child have frequent colds and/or ear infections? Yes No
Has hearing been checked? Yes No
Has eye sight been checked? Yes No
How does the child communicate? (e.g. babble, point, words)
Please provide examples:
_____________________________________________________________________________________________________
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How many words does your child use? ____________________________________________________________________
Does your child put words together? (2 – 3 word sentences) Yes No
Does your child make any sounds? (e.g. car sounds, animal sounds) Yes No
Please provide examples:
_____________________________________________________________________________________________________
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Does your child understand simple directions? (e.g. “Put that down,” “Please get your coat.”) Yes No
Does your child have an Individual Family Service Plan (IFSP/XIFSP) or Individualized Education Plan (IEP)?
Yes No
Is your child receiving any other specialized services (e.g. Occupational Therapist, Play Therapist, etc.)? ☐ Yes ☐ No
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If yes, please specify by checking one of the boxes below:
Infants & Toddlers Program
Child Find/Early Childhood Center, Prince George’s County
Private
Does your child have a diagnosis/diagnoses? Yes No
If yes, please specify by checking one or more of the boxes below:
Attention-Deficit Hyperactivity Disorder Bi-Polar Disorder Autism Spectrum Disorder
Speech and Language Delay Cognitive Delay Developmental Delay
Sensory Impairment Physical Disability Other : ______________________________
When did behavioral difficulties begin? ___________________________________________________________________
Has your child experienced any of the following?
Parent Incarcerated
Homeless
Foster Care
Adoption
Drug Exposed
Are there any other significant events in the life of the child beyond the risk factors in the previous question (e.g.
divorce, separation, new sibling, foster care, or other complex trauma)? Please describe below:
Parent or Caregiver Information/Family History
Parent or Caregiver Name(s): ___________________________________________________________________________
Parent or Caregiver Address(es): _________________________________________________________________________
Phone Number(s): _____________________________________________________________________________________
E-mail Address(es): ____________________________________________________________________________________
Primary Contact for ECMH Services: _____________________________________________________________________
Preferred Method of Contact:____________________________________________________________________________
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Parent or Caregiver Marital Status: ______________________________________________________________________
Who has legal custody? _________________________________________________________________________________
Does your family receive any of the following services?
Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Women, Infants, and Children (WIC)
Maryland Children’s Health Program (MCHP)
Child Care Subsidy
Number of siblings/children in the home (*Please provide ages): _______________________________________________
Is there any family history of hearing loss? Yes No
Is there any family history of vision impairment? Yes No
Is there any family history of any diagnosis/diagnoses (physical health, mental health, etc.)? Yes No
If yes, please describe below:
Child Care Program Details
Name of Child Care Program: ___________________________________________________________________________
Facility Type: Center Family Child Care Nursery School Montessori
MSDE Child Care License/Certificate of Approval/Letter of Compliance #: _____________________________________
Child Care Program County, State: Prince George’s County, Maryland
Child Care Program Address: ___________________________________________________________________________
Contact Information for Child Care Program:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Child Care Center Program Director Name: _______________________________________________________________
Classroom Teacher(s) Name(s): __________________________________________________________________________
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Is the child care program open year-round? Yes No
Are there changes to this child care program during the summer months? Yes No
If yes, what are the changes, e.g. staff, summer camps, change in schedule?
_____________________________________________________________________________________________________
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Within the past year, has this child care program received services through the Prince George’s Child Resource Center, e.g. Technical Assistance, Coaching, Early Childhood Mental Health Consultation? Yes No If yes, please specify (if possible):
Dates/Times child attends child care program: ___________________________________________________________
Month/Year child began attending child care program: ___________________________________________________
How long has the child been in the current classroom? _______________________________________________________
What are the triggers for your child’s behavior(s), if they have been identified? Please describe in detail below:
Do you have any concerns regarding your child in this child care program? ☐ Yes ☐ No
If yes, please describe this concern below:
What are your observations of your child in the child care program?
Has your child been asked to leave any child care program? Yes No
If yes, please describe below:
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Is your child’s Pediatrician aware of the challenges in the current child care program? Yes No
If yes, please describe their feedback below:
What are your goals/expectations of Early Childhood Mental Health Consultation? Please describe in detail below:
Caregiver Consent Agreement
I give permission for Project WIN, Early Childhood Mental Health Consultation Services to use the information
provided on this form to assist in identifying my child’s needs. I understand this also includes any preliminary
evaluations/screens used to assess my child. I understand that this information will be kept completely confidential. I
am aware that I may request this information to be removed from my child’s file if it is inaccurate, misleading or
otherwise in violation of the privacy or other rights of my child. I am also aware that I may request a copy of this
completed form for my own records.
____________________________________________________________ Date: __________________________
Name of Parent or Caregiver
____________________________________________________________ Date: __________________________
Signature of Parent or Caregiver
_____________________________________________________________ Date: __________________________
Signature of Other