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Required format:

mVdpXoSrGhw4yhvIzrIZKT2pjfKKhafjsib2sJA67cis95GMwcS6bSuIGK2BLVyemvUXxTmPhdibUQEQa

KFSC Intake Form

Please complete the survey below.

Thank you!

Thank you for reaching out to KFSC. We want to work with you to decide on the most appropriate services we can offer. Please complete this form as best as possible. Feel free to have others (physician, case manager, or school personnel) help if needed.

Participation with KFSC and Partner Organizations is voluntary. Families may withdraw their consent and intake form at any time by notifying the program in writing via email or mail. Choosing to withdraw will not affect the family's ability to receive information or seek services in the future.

Service navigation does not guarantee quicker access to services. While we understand many families are seeking support during times of crisis, service availability and timelines are determined by each community system and provider involved, not by KFSC staff.

If you are experiencing an emergency, please call 9-1-1 or the 9-8-8 suicide and crisis help line. You are also welcome to check out our resource database (https://kfsc-resources.ku.edu/) to find resources near you.
Contact the Kansas Department for Children and Family Mobile Crisis Helpline at 833-441-2240. Services are open to all Kansans 20 and younger, including those in foster care or formerly in foster care. You can call, text, or chat.

Have you completed our intake form previously?

Yes

A form has been completed by another party for this individual

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Please Note: We are committed to maintaining a respectful and professional environment for all staff and families. Abusive, threatening, aggressive, or inappropriate language or behavior toward any member of our team will not be tolerated. We ask that all communication remain respectful to ensure we can effectively support every family we serve.

Background Information

Name of Person filling out this form:

* must provide value

Will you need a language Interpreter?

Yes

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Language:

Relation to the child:

* must provide value

Parent/Caregiver

Foster Parent

Clinical Service Provider

Community Organization Staff (Foster Care Agency, Program Administrator, etc)

Direct Support Worker

Guardian of a person over 18 years of age

Other community Member

Other Service Provider

Paraprofessional

Person with a disability

School Administrator

School Mental Health Staff

Teacher

My phone number:

* must provide value

My email address:

* must provide value

Preferred method of contact:

Phone

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Parent/legal guardian full name:

* must provide value

Parent/legal guardian Phone Number:

* must provide value

Parent/ legal guardian email address:

* must provide value

Parent/legal guardian preferred method of contact:

* must provide value

Phone

Unsure

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The following information will be filled out on behalf of the child

Child's name:

* must provide value

Child's date of birth (M/D/Y)

* must provide value

M-D-Y

Child's Gender:

Male

Female

Non-Binary/Third Gender

Transgender Female

Transgender Male

Other

Decline to answer

Unknown

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Other Gender Explained:

What is the child's race and/or ethnicity? Select all that apply.

American Indian or Alaska Native: For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo community, Aztec, Maya, etc.

Asian: For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

Black or African American: For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

Hispanic or Latino: For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

Middle Eastern or North African: For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

Native Hawaiian or Pacific Islander: For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

White: For example, English, German, Irish, Italian, Polish, Scottish, etc.

Has the child ever been involved in the Foster care system?

Yes

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Does the child have any Diagnosis?

* must provide value

ADHD

Autism Spectrum Disorder

Anxiety

Major Depressive

Disruptive Mood Dysregulation Disorder

Feeding and Eating Disorders

Oppositional Defiant Disorder

Learning Disorders

OCD

PTSD

Intellectual or Developmental Disability

Other

My child does not have a diagnosis

Other:

Child's street address:

Child's City:

County:

* must provide value

Child's Zip Code:

School District (Leave blank if child is not enrolled in any school district):

Does the child attend a childcare center or preschool?

Yes

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Child's Insurance Carrier:

Were you referred to us by anyone?

Yes

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Referrals Name:

Referrals Phone Number:

Referrals email:

Referrals Agency:

Primary Concern #1 for reaching out today:

* must provide value

Expand

Primary concern #2 for reaching out today:

Expand

Primary concern #3 for reaching out today:

Expand

The Child currently has an IEP (Individualized Education Plan) or a IFSP (Individualized Family Service Plan) in place.

Yes

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Do you have concerns for school?

Yes

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Please describe your concerns with School

Do you have a Targeted Case Manager?

Yes

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Targeted Case Manager Name:

Targeted Case Manager Phone Number:

Targeted Case Manager Email:

Targeted Case Manager Agency:

Is the child on a Home and Community Based Services (HCBS) waiver?

Yes

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What waiver services does your child receive?

Autism (AU)

Intellectual/Developmentally Disabled (i/DD) 5+ years

Physical Disability (PD)

Serious Emotional Disturbance (SED)

Technology Assisted (TA)

Brain Injury (BI)

My child is on a waitlist for one, or multiple waivers

Mental Health / IDD Waiver Case Manager Name:

Mental Health / IDD Waiver Case Manager Phone Number:

Mental Health / IDD Waiver Case Manager Email:

Mental Health / IDD Waiver Case Manager Agency:

Is the child already enrolled in any behavioral or health services?

Yes

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Services:

ABA Services

CDDO (Community Developmental Disability Organization)

Therapy

Dentist Offering Sedation

Occupational Therapy

Parent Training

Physical Therapy

PRTF (Psychiatric Residential Treatment Facility)

Respite Care

Speech Therapy

Toilet Training

Waiver Services/Waiver Waitlist

Other

Other:

Please select what service you are interested in pursuing. We will follow up about the services you select.

* must provide value

I am needing support but am not sure where to start

ABA (Applied Behavior Analysis)

Parent Training

Diagnosis Services

CDDO (Community Developmental Disability Organization)

Educational Events about Autism, Foster Care and Behavioral Health

Psychotherapy

Occupational Therapy

Physical Therapy

Speech Therapy

Feeding Therapy

Respite care

Sexual Education Resources

Dentist recommendations including those offering sedation

IEP Advocacy/Education issues

I am looking for a Targeted Case Manager

Psychiatric Residential Treatment Facility Help (PRTF)

Family Custody issues involving children with ASD/IDD

General Family support and Advocacy

Transition into adulthood resources

Guardianship Questions

Waiver Information Access and Eligibility

Social Security/SSI/SSDI Questions

Medicaid services/MCO questions/EPSDT

Health insurance navigation and advocacy

Juvenile Justice Help/System Navigation

ABA Services are provided in Clinics or at Home. Do you have a preference of Clinical ABA services or Home Based ABA services?

Clinic Based ABA Services

Home Based ABA Services

No preference

Do you already have services in mind you are interested in pursuing?

Yes

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.