PMTO REFERRAL FORM Ways to GiveGive financiallyGive in KindKansas city! Charlie hustle teePlanned givingTax credits Identified Parent/Guardian to receive PMTO KansasMissouri Interpreter Needed? If yes, for which family member? * YesNo Target Child Information Placement Information (if applicable) Program Information Program Family is Receiving Services Through * ReintegrationPermanencyAftercareOther Eligibility Criteria Most families can meet PMTO Eligibility Criteria. For questions on how a family can be made eligible please contact the PMTO Clinical Manager. The identified target child must be between the ages of 3-16 and meet at least one of the below criteria: * Child has been out of the home for less than 6 monthsChild is expected to reintegrate within 90 days of referral for PMTOChild re-entered foster careFoster Family to stabilize placement In addition, the child OR parent/guardian must meet at least one of the following criteria: Child PECFAS 50+ or CAFAS 60+PECFAS 20 in 1 subscale orCAFAS 30 in 1 subscaleChild is in PRTFChild has an IEP with behavioral disordersSED waiver services by mental health centerPsychiatric inpatient treatment within the last yearTaking psychotropic medication Parent PSI- clinical significance in PCDI domainPSI- clinical significance in DC domainPSI- overall score with clinical significanceTo Stabilize Placement (Foster Family, Relative Placement, or Aftercare) If available, please attach current PECFAS/CAFAS and PSI assessment (no older than 30 days) DONATE DONATE
