Child Care Consulting Agreement Form
Complete this form to request child care consulting services and confirm the details needed to prepare your consultation.
Client and Child Details
Client / Parent or Guardian Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Number of Children Involved
*
Consulting Needs and Scheduling
Main consulting topics or concerns
*
Child behavior
Routine and schedule
Sleep habits
Nutrition and feeding
Potty training
Screen time
Enrollment and program selection
Provider communication
Safety and supervision
Other
Preferred consultation format
*
In-person
Phone
Video call
Either in-person or video
Other
Preferred days and times for sessions
*
Monday mornings
Monday afternoons
Tuesday mornings
Tuesday afternoons
Wednesday mornings
Wednesday afternoons
Thursday mornings
Thursday afternoons
Friday mornings
Friday afternoons
Evenings
Weekends
Other
Current child care situation or background
Specific goals for the consultation
*
Agreement and Submission
Acknowledgement of consulting terms
*
I agree that the consultation is advisory only and does not guarantee specific outcomes
I understand that recommendations are based on the information provided
I confirm I have read and agree to the child care consulting service terms
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Form
Submit Form
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