Program Review and Development Service Request Form
This form is to be completed by the primary child life program contact or individual seeking ACLP services. This information will be used to guide discussion and determine, with you, the best approach that matches your needs. In order to most easily complete this form, please review it in its entirety before beginning.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Institution/Agency
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
Email
example@example.com
Preferred time frame for the program review:
Please describe the primary reason for seeking ACLP Program Review & Development Service consultation:
Screening and Demographic Information
Cost of a comprehensive, 2 day review (most typical) ranges from $8,000-11,000. This fee structure is determined by the data provided below. This range does not include costs related to travel and consultants' related expenses.
Type of facility
Children’s Hospital within a Hospital
Freestanding Children’s Hospital
Hospital with Pediatric Services
Psychiatric Hospital
Rehabilitation Hospital
Community Hospital
Other
Location/Airport Code
Pediatric Bed Count
Hospital Bed Count
Annual Pediatric ED Visits
Annual Pediatric Ambulatory Visits
Annual Radiology Visits
Are you part of a multi hospital system?
If yes, do you oversee the child life departments throughout the system?
Staffing
Please enter numerical or text responses in the chart below.
Enter response here
Total Department/Program FTE's
Total Child Life FTE's
Total Number of Child Life Staff
Total Other FTE's
Dedicated Child Life Leader
If yes, Is the leader a Child Life Specialist?
If yes, what is the number of years in leader role?
Please explain the reporting structure for Child Life:
Goals for Program Review
Please describe the primary reason/goal for Program Review:
Does your executive team have knowledge and endorse the request for this review?
Does your Child Life team have knowledge and support the request for this review?
Are you planning for significant program/hospital growth?
Upon confirmation of the service, ACLP will respond with a contract, documentation describing the process, information on responsibilities of the requesting facility, profiles of the assigned ACLP reviewers, and confirmation of the financial arrangements. Requests are reviewed as they are received. Questions? Please email aclpprogramreview@childlife.org
Submit
Should be Empty: