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816-508-3500 | 844-824-8200
donate
About Us
How We're Growing
Our Philosophy
Trauma-Informed Care
Solution-Based Casework
Leadership Team
Boards
Our Mission
Diversity Statement
Join Our Team
Job Openings
Our HR Dept
Internships and Practicums
Our Locations
Our Policies
Partnerships
Chiefs Charity Game
Foster & Adoptive Care Coalition
Our Services
Youth & Family Support
Prevention Services
Intervention Services
On-Campus Living
Foster Care & Adoption
Become a Foster Parent
Foster Care Recruitment & Licensing
Treatment Foster Care
Adopt a Child
Education & Trainings
CE Classes
Training Calendar
ShowMe Healthy Relationships
Build Trybe
Day Treatment Schools
Youth Educational Success (YES)
Behavior Intervention Support Team
Pay My Bill
Our Impact
Your Stories
Newsletters
Ways To Help
Volunteer
Become a Mentor
Cornerstones of Care Champions
Give Financially
Safety STL
Back to School
2023 Chiefs Tickets
Monthly Giving
NAP Tax Credits
YOP Tax Credits
Give In-Kind
Holiday Fund
Kansas City! Charlie Hustle Tee
Host an Event
Planned Giving
Honors & Memorials
Tribute Gifts
News & Events
Newsroom
Recent News Coverage
Upcoming Events
Foster Care Live Q&A
Bright Lights Waldo Nights
Disc Golf Tournament
Pies For a Purpose
Spirit Gala
Savor the Sound
Plant Sale
Tee It Up Fore the Kids
Blog
Home
Forms
Redo-School-Based-Therapy-Referral
Redo School-Based Therapy Referral Form
Today's Date
Type of therapy
Family
Individual
Family & Individual
Preferred location
In-Person
Virtual
No preference
Caregiver is aware of referral
Yes
No
Student Information
Last Name
First Name
Middle Initial
Date of Birth
Age
School Grade
Address
City
Zip Code
Family Size
Language Preference
Gender/Gender Identity
Religion
Race
Ethnicity
Payment Method: Hazelwood School District
Guardian Information
Legal Guardian
Two Biological Parents
Two Adoptive Parents
Biological Mother Only
Biological Father Only
One Biological Parent and One Step Parent
Foster Parent(s)
Adoptive Father only
Adoptive Mother only
Aunt
Uncle
Sibling
Cousin
Grandmother
Grandfather
Children’s Division
Other
Legal Guardian Name(s)
Home/Cell #
Email
Preferred Contact Methods (check all that apply)
Home/Cell
Email
Call
Text
Can Leave a Message
Care Provider(s)
Home/Cell #
Email
Preferred Contact Methods (check all that apply)
Home/Cell
Email
Call
Text
Can Leave a Message
School Information
School Building
Social Worker/School Counselor
Social Worker/School Counselor Phone Number
Social Worker/School Counselor Email
Referral Infomation
Referral Source
Phone Number
Relationship to Student
Email
Time(s) and Day(s) student is available for therapy sessions at school
Reason for Referral
Adoption
Aggression/ Anger
Anxiety
Coping with change
Depression
Foster Care
Grief/Loss
School Aggression
School Suspensions
Social Skills
Trauma- Abuse/Neglect/Physical/Emotional
Other
Additional information related to reason for referral
Previous or Current Diagnosis , if any
Current Medications
List your desired goals and outcomes of therapy
Other Pertinent information (I.e. Specify the type of therapy recommended, preferences, and specific requests)
Type characters you see in the image below
Send