Child Care Special Needs Verification Form - Hamilton County Job & Family Services
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Hamilton County Department of Job and Family Services
Child Care Services
Special Needs Verification Form
Child’s Name:
DOB:
Caretaker’s Name:
Address:
Important:
This verification, if approved, allows certified child care home providers to be paid at a higher rate. To
be eligible for help paying for child care services, families must meet current income guidelines and all
caretakers must be employed or in approved school or training activity.
The child does not function according to age appropriate expectations in one or more of the following areas of
development: (check all that apply)
Social/emotional
Cognitive
Chronic Health Issues
Communication
Perceptual-motor
Behavioral
Physical
Please describe any area checked above
If the child is more than 12 years old, can the child independently care for herself/himself?
No;
N/A;
Yes
What special services does the child receive or require as a result of their special need? (i.e., special adaptations,
modified facilities, program adjustments or related services for the child to function in an adaptive manner)
How long (approximately) will these conditions exist?
How long will it be necessary for child care to address these conditions?
Are you a licensed physician, psychologist or psychiatrist?
Yes No
Physician’s Stamp (required)
Printed Name of Physician, Psychologist or Psychiatrist:
Date:
Signature of Physician, Psychologist or Psychiatrist:
Street Address:
City:
State:
Zip:
Phone:
*Notice:
The information on this form is time limited and will expire 12 months from the signature date
of the physician, psychologist or psychiatrist.
The child’s caretaker is responsible for sharing form copies with any child care providers.
HCJFS 3003 (REV. 3-15)
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