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