Fostering Prevention Referral

• One child needs to be between the ages of 6-17.
• The child must be living in the home with the caregiver.
• Caregivers must be open to receiving services, including participation in evidence-based parenting curriculum.

Program Eligibility Is at least one child in the home between the ages of 6 and 17?* YesNo Is the child living in the home with the caregiver?* YesNo Is the caregiver willing to receive services, including participating in the parenting curriculum?* YesNo Location FAC Location* Chillicothe Independence Joplin Kansas City, KS Pittsburg, KS Poplar Bluff Springfield   Parent 1 Information First Name* Last Name* Cell Phone* ()-ext Enter Int'l Number Home Email Street Address* City* State/Region* AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Enter Region Zip Code* County* Date of Birth Birth Parent Identified Gender* Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning   Race & Ethnicity* African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian   Sexual Orientation* Two Spirit Asexual Bisexual Gay Lesbian Pansexual Polysexual Queer Questioning Straight Decline to Answer/Unknown   Current Benefits WIC Disability Medicaid Medicare SNAP Social Security Subsidy TANF (Child Only) TANF Unemployment None   Employment Status Employed Part-Time Employed Full-Time In School Not currently employed or in school Retired Stay at Home Parent Unknown   Highest Level of Education Less than High School Some High School High School Diploma or Equivalent Some College Associate's Degree Bachelor's Degree Master's Degree Doctoral Degree   Relationship to Child (Parent 1)* Adoptive Parent Aunt/Uncle Cousin Father Foster Parent Grandparent Kinship Guardian Mother Other Sibling Step-Parent   Parent 1 Immediate services identified* Addiction Currently homeless or risk of homelessness Education Employment Financial Legal Marital/partner relationship issues Parenting skill acquisition Physical/Mental Health Social/Community Supports Transportation   Parent 1 Annual Income* $0-$10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 - $50,000 $50,001 - $60,000 $60,001 - $70,000 $70,001 - $80,000 $80,001 - $90,000 $90,001 - $100,000 $100,001 - $110,000 $110,001 - $120,000 $120,001 - $130,000 $130,001 - $140,000 $140,001 - $150,000 $150,001 and up Unknown/NA   Parent 2 Information Parent 2 Name Parent 2 Cell Phone ()-ext Enter Int'l Number Parent 2 Email Parent 2 Address Parent 2 City Parent 2 State Parent 2 Zip Code Parent 2 County Parent 2 Date of Birth Parent 2 Identified Gender Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning   Parent 2 Race & Ethnicity African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian   Parent 2 Sexual Orientation Two Spirit Asexual Bisexual Gay Lesbian Pansexual Polysexual Queer Questioning Straight Decline to Answer/Unknown   Parent 2 Employment Status Employed Part-Time Employed Full-Time In School Not currently employed or in school Retired Stay at Home Parent Unknown   Parent 2 Highest Level of Education Less than High School Some High School High School Diploma or Equivalent Some College Associate's Degree Bachelor's Degree Master's Degree Doctoral Degree   Relationship to Child (Parent 2) Adoptive Parent Aunt/Uncle Cousin Father Foster Parent Grandparent Kinship Guardian Mother Other Sibling Step-Parent   Parent 2 Immediate services identified Addiction Currently homeless or risk of homelessness Education Employment Financial Legal Marital/partner relationship issues Parenting skill acquisition Physical/Mental Health Social/Community Supports Transportation   Parent 2 Annual Income $0-$10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 - $50,000 $50,001 - $60,000 $60,001 - $70,000 $70,001 - $80,000 $80,001 - $90,000 $90,001 - $100,000 $100,001 - $110,000 $110,001 - $120,000 $120,001 - $130,000 $130,001 - $140,000 $140,001 - $150,000 $150,001 and up Unknown/NA   Case Details Reason for Referral* Please be specific in describing what parental support is needed and the strengths that have been identified within the family unit. Pertinent Family Information* History of Child Welfare Involvement* Have the children or the family come to the attention of the state child welfare agency for any reason in the past? If so, please provide information about this involvement. Is there a TAPA?* Yes No I don't know There was previously a TAPA   Date TAPA Started Date TAPA Ended Number of Adults Living in Home* Number of Total Children Living In Home* Children's Division Worker If not applicable, enter "N/A." Children's Division Worker Phone Number ()-ext Enter Int'l Number Children's Division Worker Email Referral Source* Clinton County Children's Division Greene County Children's Division Jackson County Children's Division Jasper County Children's Division Johnson County DCF Livingston County Children's Division Medical Provider Mental Health Center/Provider Parent (Self-Referral) Relative Social Service Agency (Specify Below) Wyandotte County DCF   Referral Source Contact Information* Name, Phone, Email...etc.

Children Involved

*This information is required*

Children Involved 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

	Name*	Date of Birth*	Relationship to Parent/Guardian*	Target Child
			Daughter Son Grandchild Step-Child Foster Child Other	YesNo

	Child Race & Ethnicity	Identified Gender	DCF Client ID (Child)
	African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian	Agender Female Gender Fluid Gender Queer Male Nonbinary Transgender, female Transgender, male Two Spirit Prefer Not to Answer Questioning

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