Child Life Program Directory Update Request
Child Life Program Information
Child Life Program Name
*
Year the Program Began
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Type
*
Please Select
Free-Standing Children’s Hospital
Free-Standing Children’s Academic Hospital
Pediatric Service/Department in an Adult Hospital
Children’s Hospital within an Adult Hospital
Children’s hospital within an adult academic hospital
Community hospital that is part of a healthcare system
Community hospital that is NOT part of a healthcare system
Adult hospital that is part of a pediatric healthcare system
Adult hospital that is NOT part of a pediatric healthcare system
Illness-specific hospital
Rehabilitative hospital
Alternative site
Email (as to be shown in Child Life Program Directory)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Program Description
*
Internships
Does this program offer internships?
*
Yes
No
Internship Coordinator
*
Number of internship hours offered
Internship Requirements (please check all that apply)
Affiliation with a College or University
Completed BA/BS
Completed Practicum
Relevant Volunteer Experience
Relevant Work Experience
None of the above
Other
Does this program follow the ACLP recommended application deadlines?
Yes
No
Does this program accept unaffiliated internship students?
Yes
No
Does this program require liability insurance for unaffiliated interns?
Yes
No
Does the internships require application materials in addition to the common application?
Yes
No
Does the internship application require official transcripts?
Yes
No
Does the internship require in-person interviews?
Yes
No
Please list how many internship openings you anticipate for each of the following cycles:
Practicums
Does this program offer practicums?
*
Yes
No
Practicum Coordinator
Number of practicum hours offered
Practicum Requirements (check all that apply)
Affiliation with a College or University
Relevant Volunteer Experience
Relevant Work Experience
None of the above
Other
Does this program accept unaffiliated practicum students?
Yes
No
Does this program require liability insurance for unaffiliated practicum students?
Yes
No
Does this program require liability insurance for unaffiliated practicum students?
Yes
No
Does the practicum application require official transcripts?
Yes
No
Does the practicum require in-person interviews?
Yes
No
Please list how many practicum openings you anticipate for each of the following cycles:
Fellowship
Does this program offer fellowship?
*
Yes
No
Fellowship Coordinator
How many fellowship openings are available annually?
Fellowship Description
Volunteer Opportunities
Are there hospital wide volunteer opportunities at your hospital?
*
Yes
No
If yes, please provide contact information for the hospital volunteer program.
How many hospital volunteers are there?
Are there child life specific volunteer opportunities at your hospital?
*
Yes
No
If yes, please provide contact information for the child life volunteer program.
How many child life program volunteers do you have?
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Hospital Profile
Main Facility - Pediatric Hospital Bed Breakdown
*
Satellite Locations - Pediatric Hospital Bed Breakdown
Areas Where Child Life Services Are Provided ON the Main Campus - check all that apply
Ambulatory Clinics (Primary Care & Specialty)
Ambulatory Surgery
Children of Adult Patients
Emergency Center
Inpatient Acute Care
Inpatient Critical Care (includes PICU, NICU and CICU)
Inpatient Hematology/Oncology
Pain Service
Palliative Care Service
Psychiatry
Radiology
Transitional Care
Trauma Service
Urgent Care
None of the above
Other
Areas Where Child Life Services Are Provided OFF the Main Campus - check all that apply
Ambulatory Clinics (Primary Care & Specialty)
Ambulatory Surgery
Children of Adult Patients
Emergency Center
Inpatient Acute Care
Inpatient Critical Care (includes PICU, NICU and CICU)
Inpatient Hematology/Oncology
Pain Service
Palliative Care Service
Psychiatry
Radiology
Transitional Care
Trauma Service
Urgent Care
None of the above
Other
Indicate which division the Child Life Department reports to:
Hospital Administration
Nursing
Patient/Family Services
Pediatric Administration
Social Work
None of the above
Other
Number of WEEKDAYS the child life program is staffed (Monday - Friday)
Number of WEEKEND days the child life program is staffed (Saturday - Sunday)
Please indicate if/how the following complimentary programs are managed at your hospital.
Animal Assisted Activities (Pet Therapy) Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Art Therapy Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Arts in Medicine Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Clown Care Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Facility Dog Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Inpatient Hospital-Based Playrooms Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Integrative Care Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Music Therapy Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Outpatient Play Space Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Outdoor Play Space Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Outdoor Healing Space Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Recreation Therapy Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Resource Library Space Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Sensory Integration Space Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Sibling Drop-Off Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Volunteer Program
*
Please Select
Offered by the Child Life Department
Offered by the Hospital/Other Department
Managed by the Child Life Department
Managed by the Volunteer Program
This program is not offered
Total number of child life program staff (Includes: Headcount for all staff that are considered under the umbrella of Child Life (regardless of funding source, role, or facility location). Includes: PRN (per diem) staff and fellows that are considered a paid position. Excludes: Non-paid students should be excluded from your overall headcount.)
*
Total number of child life FTE (Includes: All staff that are considered under the umbrella of Child Life (regardless of funding source, role, or facility location). Includes: Fellows that are considered a paid position. Excludes: Non-paid students should be excluded from your overall headcount.)
*
Child Life Services
How do patients receive child life services?
A patient referral or consultation is required for all child life programs and services
A patient referral or consultation is required for some child life programs and services
A patient referral or consultation is not required for child life programs and services
No information provided
Please select the areas where child life services are provided on the main campus.
Ambulatory Clinics (Primary Care & Specialty)
Ambulatory Surgery
Children of Adult Patients
Emergency Center
Inpatient Acute Care
Inpatient Critical Care (includes PICU, NICU, and CICU)
Inpatient Hematology/Oncology
Pain Service
Palliative Care Services
Psychiatry
Radiology
Transitional Care
Trauma Service
Urgent Care
None of the above
No information provided
Other
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Submitter's Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
ACLP Number
Please verify that you are human
*
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