Health Consultation Request

To receive consultation services, please submit your questions/concerns below. You can include any description that will help us begin to understand your question. Since we do not diagnose or treat individual children — and to protect privacy— please do not include any identifiable information on a specific child. In many cases, we will connect with you to gather additional information so we can give you the best possible answer.

ECHC Health Consultation Request Form

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email(Required)

Role at Center/Program(Required)

Name of Child Care Center/Provider(Required)

Provider Number(Required)

Location Number(Required)

City(Required)

County/Tribe(Required)

Zip Code(Required)

What can we help you with?(Required)

Preferred Method of Contact(Required)

Best Times to Contact(Required)

Expedited Response

Please prioritize a response as my need is time-sensitive

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Reason for Consult

Name

This field is for validation purposes and should be left unchanged.

How does this service work?
Explore Our Consultation Process