Referral Form

Due to the high volume of referrals, please allow 5 business days for your referral to be addressed and assigned to a provider

Please note that we only accept CTS funds, self pay, KVC, PCHAS, MBCH, MO Alliance, Medicaid, Home State Health & UHC Managed Care Medicaid funding at this time.
Medicaid will NO LONGER cover IFS services
Once your referral is submitted successfully, you will be notified when the screen refreshes. If you don't get a "Success" message after clicking the submit button, please ensure that all information with a red astrick is complete.
*Please email [email protected] to refer a student for school based services

Learn more about IFS

* Indicates required field

Client name *

Client Date of Birth: *

Client Phone Number (If client is a minor, type "minor"): *

Client Address: *

Case Worker / Referring Professional Name *

Caseworker / Referring Professional Email Address: *

Who is completing this referral? *

Case County *

If the client is a minor, provide Name of Adult for scheduling, Relation to client, and Phone number: *

Case Goal *

If referring for visitation: Name and Age of Children *

Please provide a short summary of the safety concerns that have prompted this referral *

**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].

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Referrals

**Due to the high volume of referrals, please allow 5 business days for your referral to be addressed and assigned to a provider**

Due to the high volume of referrals, please allow 5 business days for your referral to be addressed and assigned to a provider