Child Care Health Consultant Inquiry Form

Contacting

Childcare Health Advocate Program

The following information will be shared with the Child Care Health Consultant(s) in order to coordinate services.

Please note that each consultant will receive a separate inquiry form. Consultants will not be informed of any other consultants you may be reaching out to.

Contact Name

Contact Phone Number

Contact Email

Preferred Method of Communication

Phone

Text Message

Preferred Contact Hours

Organization

If this does not apply to you, please put N/A.

Type of Child Care Provider

Other Service

Please expand more on your needs

Please do not include personally identifiable information about children in your care in this section.

How many infant rooms does your child care have?

Mode of Service

Virtual (i.e. Phone Call, Email, Video Call)

Hybrid

In-person

Address Where Service is Needed At

Preferred Service Hours

Any additional details you'd like to add?

Submit

Contacting

Preferred Method of Communication

Type of Child Care Provider

Type of Service Needed

Mode of Service