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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.

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*  
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  
Diagnoses
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?
Grade*
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
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.