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CCYT Referral Form

 FosterAdopt Connect

Community Connections YouThrive helps current and former foster youth navigate the struggles of approaching adulthood. In order to be eligible for CCYT, the young person must meet the following criteria:
  • They are 17-26 years old
  • They are/were in the Missouri and/or Kansas foster care system. 
  • They reside in one of the following counties:
    • Kansas Counties: Johnson, Leavenworth, Reno, and Wyandotte
    • Missouri: Butler, Greene, Jackson, and their adjacent counties. 

Referral Details
Referring Agency*  
Program Referrer*
Referrer Phone Number*
()-ext
Enter Int'l Number
Referrer Email*
FAC Location*  
Child Welfare Information
What is Client's Current Foster Care Status?*  
In which state(s) did the client spend time in foster care?*
 
Case Management Agency*  
Case Manager
Case Manager Email
Client Information
Youth First Name*
Youth Last Name*
Youth Date of Birth* Calendar
Youth Phone Number*
()-ext
Enter Int'l Number
Youth Email
Address
How would you describe the youth's stability at their current placement?  
Youth County of Residence*
Youth Race & Ethnicity*
 
Gender*  
Sexual Orientation*  
Language*  
Services Needed
Is client currently homeless?*
Is client currently working?*
Last grade completed*
CCYT Domains Needed*
 
How would you like Community Connections Youth Thrive to help?*
COMBAT questions
Questions for Combat funding survey. Please select all that apply.
COMBAT Queries*
 
Currently receiving mental health services  
Ever been hospitalized for psychiatric needs  
Ever received treatment for substance abuse  
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