Child Profile

TA# CEL
office use only

For

Please complete this form if you are requesting assistance with a specific child. Prior to completing this form, the child's parent or guardian must have completed the "Consent for Release of Information." Person completing this Carlena Lowell & Jill (consultee) form: Date: 1/29/13 Child's Name: *names changed Tyler Child's DOB: 7/8/2009
for confidentiality

Child's parent(s) or guardian(s): Child's primary language: English Name of program this child attends: Name of classroom and teacher:

Rachel Child's secondary language:

2-Head Start and afternoon day care twice a week

Classroom A - Jill

1. Check the child's primary diagnosis or specify the reason for the request (at risk behavior, etc.).
Autism Deaf-blindness Deafness Developmental delay Emotional disability Hearing impairment Mental retardation Multiple disabilities Orthopedic impairment Other health impairment Specific learning disability Speech/language impairment Traumatic brain injury Visual impairment ADHD Sensory motor/sensory integration issues At risk behavior/challenging behavior If none of the above, please specify the reason for the request:

2. Child/Family Services - Please check all that apply:

Child Development Services (CDS) Early Intervention/Special Education Services Mental Health Services MaineCare/Katie Beckett Maternal Child Health Special Health Care Foster Care Services

ASPIRE/TANF (Temporary Assistance to Needy Families) Child Protective Services DHHS Child Services - Specify Other: (please list)
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Voucher

Voucher Waiting List

Contracted Slots

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3. Does this child have a current IFSP/IEP? 4. Do you have a copy of the IFSP/IEP? Date of receipt: 11/26/2012

Yes

No

Don't Know

Yes

No

Don't Know

5. How long has this child been in the program?

One month or less Two to four months Five months or more

6. Has this child previously been expelled from another program?

Yes No Don't Know

If yes, please explain:

Child Behavior Child Medical Issues Other (please explain)

7. Is this child's placement currently at risk? If yes, please explain:

Yes

No

8. Do you have anything in writing that describes your process for disenrolling children?
Yes No

If yes, please explain:

If a child has not been present for 30 days and the staff has attempted to contact the family sev 9. What do you feel is needed to ensure this child's success in your setting?

Tyler would benefit from approriate extra support, environments conducive of emotional express 10. What has been discussed with the family about your concerns?

Conversations regarding Tyler's anger, separation anxiety, and potty training have been had wit 11. How does the family want to participate in the consultation?

Rachel would like to participate by providing input of Tyler's strengths, concerns and behaviors a

12. What else do we need to know about this child to better support your request? Tyler lives with his mom, and they receive support from her parents and friends. Rachel had re
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Tyler lives with his mom, and they receive support from her parents and friends. Rachel had re

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