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 Parent/Caregiver Other

Please explain your role:

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

Age(s) of Children *:

Infant

Toddler

Preschool

Name of Program: *

For example, the name of your childcare program.

About the Children You Serve

Childcare Center Type: Please select: Center Family Home Group Home License-Exempt Center-Based Family Child Care GSRP Home-Based

Number of Children Served:

Number of Childcare Providers:

Are you a GSRP or Strong Beginnings program? Please select: GSRP Strong Beginnings No or N/A

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

Emotional and Behavioral Concerns

Relationship and Attachment Concerns

Developmental and Social Concerns

Other

Please explain “Other” *:

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

Availability

How would you prefer to be contacted for your initial follow-up? *

Phone

Email

No Preference

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?

How did you hear about Social Emotional Consultation? * Please select: Another child care provider or early childhood professional Program director, administrator, or supervisor A Social Emotional Consultant Resource Center Great Start Collaborative or other local early childhood partner Child Care Licensing GSRP / Intermediate School District (ISD) Training, conference, presentation, or community event Email or newsletter Social media Website / online search A family or friend I have used Social Emotional Consultation before Someone who has used consultation recommended it to me I’m not sure / I don’t remember Other

Please explain how you heard *:

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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