Parent Support & Prevention Program Referral
The
Parent Support & Prevention
Program
provides assistance to families who are at risk of child welfare involvement. In order for a family to be eligible for
Parent Support & Prevention Program
services, they must meet the following criteria:
One child needs to be between the ages of 0-17.
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.
Parent Support & Prevention Program is currently
only
serving the following areas out of our respective branch offices:
Independence
(Jackson County)
Chillicothe
(Livingston, DeKalb, Caldwell, Daviess, & Clinton Counties)
Hannibal
(Adair, Chariton, Clark, Knox, Lewis, Lincoln, Linn, Macon, Marion, Monroe, Pike, Ralls, Schuyler, Scotland, Shelby, & Sullivan Counties)
Joplin
(Jasper, Newton, McDonald, Barton, Vernon, Cedar, & Dade Counties)
Springfield
(Greene, Bates, Henry, St. Clair, Polk, Hickory, Webster, Christian, Taney, Lawrence, Barry, & Stone Counties)
Poplar Bluff
(Stoddard, Carter, Ripley, Wayne, & Dunklin)
The
Parent Support & Prevention
Program
provides assistance to families who are at risk of child welfare involvement. In order for a family to be eligible for
Parent Support & Prevention Program
services, they must meet the following criteria:
One child needs to be between the ages of 0-17.
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.
Parent Support & Prevention Program is currently
only
serving the following areas out of our respective branch offices:
Independence
(Jackson County)
Chillicothe
(Livingston, DeKalb, Caldwell, Daviess, & Clinton Counties)
Hannibal
(Adair, Chariton, Clark, Knox, Lewis, Lincoln, Linn, Macon, Marion, Monroe, Pike, Ralls, Schuyler, Scotland, Shelby, & Sullivan Counties)
Joplin
(Jasper, Newton, McDonald, Barton, Vernon, Cedar, & Dade Counties)
Springfield
(
Greene, Bates, Henry, St. Clair, Polk, Hickory, Webster, Christian, Taney, Lawrence, Barry, & Stone Counties
)
Poplar Bluff
(Stoddard, Cart
Program Eligibility
Is at least one child in the home between the ages of 0 and 17?
*
Yes
No
Is the child living in the home with the caregiver?
*
Yes
No
Is the caregiver willing to receive services, including participating in the parenting curriculum?
*
Yes
No
Location
FAC Location
*
Chillicothe, MO
Hannibal, MO
Independence, MO
Joplin, MO
Kansas City, KS
Pittsburg, KS
Poplar Bluff, MO
Springfield, MO
Wichita, KS
Parent 1 Information
First Name
*
Last Name
*
Cell Phone
*
Enter International
Home Email
Street Address
*
City
*
State/Region
*
Select US-State
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
Enter International
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
*
Pertinent Family Information
*
History of Child Welfare 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
Children's Division Worker Phone Number
Enter International
Children's Division Worker Email
Referral Source
*
Big Brothers Big Sisters
Care Portal
Juvenile Intake and Assessment Center
Kansas DCF
Medical Provider
Mental Health Center/Provider
Missouri Children's Division
Parent (Self-Referral)
Relative
Schools
Social Service Agency (Specify Below)
Referral Source Contact Information
*
Referral Source Contact Person
Referral Source Contact Phone Number
Enter International
Referral Source Contact Email
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
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Name
*
Date of Birth
*
Relationship to Parent/Guardian
*
Daughter
Son
Grandchild
Step-Child
Foster Child
Other
Target Child
Yes
No
Identified Gender
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child Race & Ethnicity
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Submit
