Submit a Referral

K.I.D.S. NW Behavior Services Referral

This referral form is intended to begin the process of enrolling a member into KIDS Behavior Services. Once this form has been received, a member of the KIDS NW Behavior Department will contact the Service Coordinator to request additional documentation and service agreements if this appears to be a good fit. *This form is secure and HIPAA compliant. If there are any questions or concerns feel free to contact us at (503)-437-4917 or info@kidsnw.org

Name of Member's Service Coordinator*
First Last
Member's/Families Preferred Language*
- English
- Spanish
Member's Name*
First Last
Member Date of Birth*
Parent/Guardian Name*
First Last
Phone Number to contact Member and/or Member's Parent/Guardian
Residential Address*
Street Address City State ZIP
Email*
Reason for Referral (Exhibited behaviors, Duration, Frequency, Antecedents)*
What Services are You Interested In?*
- Select All
- Attendant Care
- Behavior Services
Upload ISP
Max. file size: 256 MB.
Previous Interventions Attempted and Outcomes*
Therapy Services Utilized (Current or Previous)*
Diagnosis/Diagnoses*
Has a Positive Behavior Support Plan already been put in place for this member? (If YES, a KIDS NW representative will request this document before initiating services.)
- Yes
- No
How many Behavior Support hours are currently approved for this member?
If behavioral hours have currently been used by another agency, please indicate how many hours left will be authorized.
Additional Information (if necessary)*
By submitting this form I understand that I am authorizing the following: *KIDS, LLC to contact me about services. *For KIDS, LLC to share any pertinent information, history, and documentation with the Direct Support Professional that I have selected to provide services so that they are educated on the care that is needed. I understand that I may revoke this approval to share information by emailing Info@kidsnw.org.
Comments
This field is for validation purposes and should be left unchanged.