Reach Out to Connect Kids (ROCK) Referral Form
This form is not monitored 24/7. We adhere to strict confidentiality. However, if there is a safety risk concern, we are mandated to report to the appropriate authority.
Referral Source Info
Name:
Organization:
Role:
Preferred method of communication:
E-mail
Phone call
Video call
Preferred contact info:
Reason for referral/questions:
Information Regarding this Child
Are parent(s)/guardian(s) aware of this referral:
Yes. (Please upload a signed consent form to The Source)
No. (Please only include the first name of the child)
Upload signed consent form here:
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Child's Name:
Age:
Please Select
0
1
2
3
4
5
Gender:
Male
Female
Non-assigning
Race/Ethnicity: (Check all that apply)
White, non-Hispanic
Black/African American
Asian
Hispanic, Latino or Spanish origin
Some other race
Please specify other race:
Home language: (Check all that apply)
English
Spanish
Some other language
Please specify other language:
Staff assigned to child:
Attempted strategies:
Room Set-up
Noise Level
Lighting
Visual Routine
Daily Schedule
Class Rules
Individualized Attention
Transitions
I Love You Rituals
Safe Place/Quiet Area
Intentional Connection Time
Other attempted strategy:
Other important notes:
After your ROCK referral is received, you will be contacted by one of the infant/early childhood consultants who will explore the current needs and concerns, and discuss the next steps.
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Should be Empty: