BI Referral form

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*
Person Completing Referral*
Referral Contact Information*

Child Demographics
Child First Name*
Child Last Name*
Child Birth Date*
DCN / Medicaid #*
Child Race and Ethnicity	African American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
Gender*
Sexual Orientation*

Caregiver Information

Caregiver Type*

Caregiver(s) Name*

Caregiver Address*

Caregiver Phone Number*

()-ext

Enter Int'l Number

Caregiver Email

Professional Team Information

Case Management County*

Case Manager

Case Manager Email

Case Manager Work Phone

()-ext

Enter Int'l Number

Case Manager Cell Phone

()-ext

Enter Int'l Number

Therapist Name

Therapist Phone Number

()-ext

Enter Int'l Number

Client Placement Status

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?*	YesNo
If yes, what are they and what accommodations are made?
Grade*
School of Attendance*
Does child have an Individualized Educational Plan?*	YesNo
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)	Child Abuse and/or Neglect Domestic Violence Sexual Abuse Underserved

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.

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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.

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