Foster Adopt Connect Home
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.
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
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Multiracial/Other
Native Hawaiian or Other Pacific Islander
Unknown
White or Caucasian
Gender
*
Female
Male
Nonbinary
Prefer Not to Answer
Transgender, female
Transgender, male
Sexual Orientation
*
Asexual
Bisexual
Decline to Answer/Unknown
Gay
Lesbian
Pansexual
Polysexual
Queer
Questioning
Straight
Caregiver Information
Caregiver Type
*
Adoptive Parent #1
Adoptive Parent #2
Biological Parent #1
Biological Parent #2
Foster Parent #1
Foster Parent #2
Hospitalization Placement
Kinship Parent #1
Kinship Parent #2
Relative Parent #1
Relative Parent #2
Residential Placement
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
Adopted
Assisted Living Program
Biological
Foster Care
Homeless
In residential
Living Independently
Living with Parent, Relative, Social Support, etc.
Unknown
Diagnoses
Mental Health Diagnoses
*
ADD
ADHD
Adjustment Disorder
Anxiety
Attachment Issues
Autism
Bi-Polar Disorder
Conduct Disorder
Depression
DMDD
FAS
Impulse
Int Explosive Disorder
Intellectually Disabled
Mood Disorder
Neurodevelopmental Disorder
None at this time
OCD
ODD
Other
PTSD
RAD
Schizophrenia
Sensory Processing
Traumatic Brain Injury
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
*
1 time per day
2-3 times per day
4-5 times per day
Several times per day
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?
*
Yes
No
If yes, what are they and what accommodations are made?
Grade
*
School of Attendance
*
Does child have an Individualized Educational Plan?
*
Yes
No
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.
