Referral Request

	I. General Information
	Parent/Guardian's Name:
	Street Address:
	City, State Zip Code:
	Daytime Phone Number:	(phone number with no dashes example:2485551234)
	E-mail Address: (for emailed referrals only)
	Fax Number: (Optional)
	Employer of Parent/Guardian: (Optional)	We are contracted by some employers to offer additional services to their employees.
	2nd Parent Employer
	Is either parent an active member of the military?
	Birthdate(s) of children (or due date):

	II. Search Criteria
	Cities to Search:	(enter 2 cities maximum)
	* You may submit additional referral requests if you require a search of more than 2 cities.
	Type of Care:
	Start Date of Child Care:	(enter in the format mm/dd/yyyy):
	Days Care Is Needed: (select one or more)
	Time Care Is Needed:	From: To: (include am or pm after the time)
	Type of Schedule:
	Special Program: (Optional)
	Other Care Options: (Optional)
	For Bi-Lingual child care please select a language:
	Do you need a child care provider that cares for children with:

	III. Subsidy
	Is Department of Human Services (DHS) helping to pay for care?
	DHS offers a program to assist low to moderate income families pay for child care. Eligibility is based on family size and yearly income. To qualify, the gross yearly income must be below the amounts listed in this chart. Family Size Yearly Income 2 $19,300 3 $23,900 4 $28,400 5 $32,950 6 $37,500 7 $42,000
	Would you like a Department of Human Services (DHS) application mailed to you?

	IV. Reason For Care
	What is your reason for needing child care? (select one or more)
	How were you referred to us?
	How would you like us to send your referral?
	*The following information	is optional and is collected for statistical purposes only.
	What is your age?
	What is your employment status?
	If you speak another language in the home, please indicate which language?
	What is your family size?
	What is your relationship to the child(ren)?
	What is your Ethnic Background / Race?
	Additional Comments:
		If you do not receive your referral list within two business days please contact us at 248-333-9545.
	If you would you like to be added to our email distribution list please enter your email address.	email address:

It is the policy of the Oakland County Child Care Council to keep all personal information shared by clients confidential. All information gathered is for statistical purposes, and no information is shared with outside parties. Personal information is defined as name, address, phone number, or fax number and email address.

The Oakland County Child Care Council strives to provide the best resource and referral service possible. We are committed to resolving service complaints to the best of our ability, as well as guiding clients through the Licensing Complaint process should a concern about a child care provider arise.

Licensing Complaint: Client/Parent has a concern or complaint about the health, safety or quality of a child care provider.

Service Complaint: Client/Parent has a concern or complaint with the quality of service received from R&R Counselor.

Client with concern about service contacts the Executive Director via phone, fax or email. Executive Director verifies information received by complainant and documents concerns in writing. Executive Director addresses concern with appropriate staff and works toward resolution – shares results of investigation with complainant and works with complainant to meet his/her needs. Executive Director documents in writing all conversations with complainant and staff. Written documentation is kept on file.

Child Care Referral Request

Child Care Referral Request Form