Virtual Infant and Early Childhood Mental Health Consultation (IECMHC) Interest Form

Thank you for your interest in Virtual Infant and Early Childhood Mental Health Consultation (IECMHC). Our services support the social and emotional well-being of young children by partnering with the adults who care for them.

Please complete this form to help us connect you with the support that best meets your needs.

Note: this program is currently open for Michigan residents ONLY.

About You

First Name: *

Last Name: *

Email: *

Phone: *

Your Role: * Please select: Teacher Assistant Teacher Administrator/Director Family Child Care Provider Home Child Care Provider Other

Please explain your role:

Age(s) of Children You Support *:

Infant

Toddler

Preschool

Number of Children Served: *

Number of Childcare Providers: *

Childcare Center Type: * Please select: Center-Based Family Child Care GSRP Home-Based

Name of Program: *

For example, the name of your childcare program.

City: *

County: * Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw St. Clair St. Joseph Sanilac Schoolcraft Shiawassee Tuscola Van Buren Washtenaw Wayne Wexford

Service Type

Which type of support are you interested in? *

Quick Connection (1–3 touchpoints): I need help with a specific question, concern, or challenge and would benefit from brief support. Support may be provided during an agreed upon time or during virtual office hours on a first-come, first-served basis.

Steady Support (up to 10 touchpoints to learn, plan and coach): I’m looking for consistent support over time to strengthen relationships, improve practices, and address ongoing needs.

Focus of Support (Social/Emotional Only)

What would you like help with? *

A specific child or family

Classroom or program-wide support

Staff stress or well-being

Professional development

Other

Please explain “Other” *:

Briefly describe your current concerns, goals, or time-sensitive considerations: *

Availability

Preferred Days for Virtual Consultation *:

Monday

Tuesday

Wednesday

Thursday

Preferred Times for Virtual Consultation *:

Morning (9am-noon)

Afternoon (noon-4pm)

Early Evening (4pm-6pm)

Other

Is there anything else you would like us to know before we connect you with a consultant?

I agree: *

Your name, email, and any other information you provide will only be used for responding to your questions. Any information you provide will never be sold, shared, or used for any other purposes.

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