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BI Referral form

FosterAdopt Connect
This is the referral form for the BI program.  Please fill this form out if you are seeking services for a child with severe behaviors.
NOTE: Currently, we are only able to serve clients within 35 miles of our branch locations in Independence, Missouri, Springfield, Missouri, and Lenexa, Kansas.

Referral Information
Date of Referral* Calendar
Person Completing Referral*
Referral Contact Information*
Child Demographics
Child First Name*
Child Last Name*
Child Birth Date* Calendar
DCN / Medicaid #*
Child Race and Ethnicity
Sexual Orientation*  
Caregiver Information
Caregiver Type*  
Caregiver(s) Name*
Caregiver Address*
Caregiver Phone Number*
Enter Int'l Number
Caregiver Email
Professional Team Information
Case Management County*  
Case Manager
Case Manager Email
Case Manager Work Phone
Enter Int'l Number
Case Manager Cell Phone
Enter Int'l Number
Therapist Name
Therapist Phone Number
Enter Int'l Number
Client Placement Status  
Mental Health Diagnoses*
Other Mental Disorder
If you checked other, please list the diagnosis here.
Prescribed Medications
Child Information
Past Trauma History and/or Reason for State Involvement*
Residential/Hospitalization History*
Number of days in residential/acute PRIOR to BI*
Child's Personality*
Client Strengths:*
Strengths of the Family
Child Favorite Activities/Hobbies*
Activities Child Struggles to Complete Independently*
Typical Behaviors Displayed in the Home*
Known Triggers*
Frequency of negative behaviors that disrupt family functioning*  
Intervention Techniques that Work*
Intervention Techniques that do NOT Work*
Most difficult time of the day and/or most difficult activities for participation*
Child expectations and responsibilities
Does the child have any physical disabilities?*
If yes, what are they and what accommodations are made?
School of Attendance*
Does child have an Individualized Educational Plan?*
Child performance/behavior at school*
Child Specific Goals for BI*
Neurostimulating activities that have been completed with a professional in the past*
What other types of community resources have been utilized or exhausted, or are currently being used? --If known, specific names of who is providing services.
Other Referral Notes
Types of Trauma (check all that apply)
If you have additional questions please call 816-350-0215 in the KC metro area
you can call 417-866-3672 in the Springfield metro area. 
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If you have additional questions please call 816-350-0215 in the KC metro area or you can call 417-866-3672 in the Springfield metro area.