MEP
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Services
Regional Partnership Grant
Community Leader
Referral Form
About Us
Please note that we only accept CTS funds, self pay, KVC, PCHAS, MBCH, MO Alliance funding at this time.
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Indicates required field
Client name and DOB
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Case Worker / Referring Professional Name
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Client Phone Number
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If referred for RPG or Drug Testing; Client Address:
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Caseworker / Referring Professional Email Address:
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Referral Source
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Client - self referred
Children's Division
MBCH
KVC
MO Alliance
PCHAS
Other
Case County
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Please select the services needed. Select all that apply.
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Level 1 Supervised Visitation - Minor safety concerns, some parent education might be necessary
Level 2 Supervised Visitation - Major safety concerns, Parent education and guidance will be necessary
RPG program (Dallas, Webster, Polk, Taney)
Substance Use Assessment
Substance Use Outpatient Counseling
Individual Therapy (Adult)
Family Therapy
Couples Therapy
Anger Management
Parent Education Class
Co-Parenting Class
Love Notes (youth sex education)
~Are virtual services approved for class participation?
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Yes
No
~Are virtual services approved for individual therapy or substance use outpatient counseling?
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Yes
No
~Are virtual services approved for visitation?
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Yes
No
Drug Testing Needed?
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No
7 panel UA (sent to lab)
7 panel UA (sent to lab) ADD fentanyl testing
12 panel instant UA
12 panel instant plus alcohol
10 panel hair follicle
10 panel hair follicle ADD fentanyl testing
Frequency of Drug Testing
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One Time
Weekly (random)
Weekly (regular scheduled day/time)
Monthly
If more than one drug testing option was selected, please specify frequency for each type of test
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If referring for visitation: Name and Age of Children
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If referring for visitation services: Placement Contact Information
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How many hours per visit:
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Frequency of Visitation
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Weekly
Bi-Weekly
Monthly
Twice Per Week
Three Times Per Week
Please list the availability of all who will be affected by scheduling services:
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Please provide a short summary of the safety concerns that have prompted this referral
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**If this referral is being submitted by an attorney or parent involved in a custody situation; please email the current court ordered visitation plan to
[email protected]
following the submission of this referral form. Visitation will not be started without a court (judge) signed visitation plan.
**We ask that you give us 48-72 hours to receive, process, and evaluate if Missouri Empowerment Project is able to provide services to the individual/family you have referred. If you have questions, please email
[email protected]
.
Submit
Home
Services
Regional Partnership Grant
Community Leader
Referral Form
About Us