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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*
FAC Location  
Child Demographics
Child First Name*
Child Last Name*
Child Birth Date* Calendar
DCN / Medicaid # /FACTS*
Child Race and Ethnicity*
 
Gender*  
Sexual Orientation*  
Caregiver Information
Caregiver Type*  
Caregiver(s) Name*
Caregiver Address*
Current Zip Code*
Caregiver Phone Number*
()-ext
Enter Int'l Number
Caregiver Email*
Household Income*  
For data purposes only
Total Number of Household Members*
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.
Child Information
Past Trauma History and/or Reason for State Involvement*
Residential/Hospitalization History*
Number of days in residential/acute PRIOR to BI*
Typical Behaviors Displayed in the Home*
Does the child have any physical disabilities?*
If yes, what are they and what accommodations are made?
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.
 
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