Submit a Request

Please fill in the questionnaire below and you will receive a response within one business day.


Email service providers frequently move emails into junk or spam folders. It is important to check these folders if you do not see our email in your inbox. You may also want to add to your Contacts List. Please contact us if you do not receive your referrals. We will email them again or mail them to you.


Your information is confidential and is gathered for referral and statistical purposes only. It will be sent across a secure and encrypted connection. It will never be shared with anyone outside of Child Care Council of Suffolk, Inc. Click here to read our privacy policy in detail.


The providers referred to you will meet the criteria that you enter in this form. The information is reported to the Child Care Council of Suffolk, Inc. by the providers themselves. We offer referrals, not recommendations. Families should call providers to ask about their program and about openings for your child. Parents should always visit the program before choosing a child care provider. The Child Care Council of Suffolk, Inc. is not liable for any activities resulting from your use of this service, including but not limited to: your family obtaining suitable care; the actions or conditions of any provider; the completeness or correctness of any listing; or the quality or availability of care, among others. If you are dissatisfied with a provider or discover that a provider does not match the description, please notify the Child Care Council of Suffolk. You can also call the New York State Office of Children and Family Services (the state agency that regulates child care and investigates regulatory complaints) at 631-240-2560.

All fields marked * are required.

First Name *
Home Address
Address 1 *
Address 2
City *
State *
Zip *
Phone 1 *
Phone 2
Email *
Last Name *
If you're looking for care near work, school or some other specific location, please provide that address below
Address 1
Address 2
Spouse's Employer
Family Composition

Relationship to Child

Location of Care *
(Choose all that apply)

Are you receiving County Child Care Subsidy Assistance? *
(Click here for more information regarding eligibility)
Reason for Seeking
(Choose all that apply)

Referred By

Child's Name
Child's Date of Birth *
Date Care Needed *
Hours Care Needed
From To
Type of Care *
(Choose all that apply)
(Click Here to review
different types of care)

Elementary School
(School age children only)
Additional Care Services

Special Needs


Please enter any comments or questions below