Beacon Tree Foundation · Family Assistance Program

Caseworker Contact Information

Caseworker/Provider Name

*

First Name

Last Name

Is there a second caseworker for this child?

*

Check here if there is another caseworker

Yes

No

Phone

*

Email

*

Verify Email

*

Caseworker Number 2

First Name

Last Name

Phone for Caseworker #2 (if applicable)

Email for Caseworker #2

In case there is more than one caseworker contact for this family

Verify Email

Organization

*

This is the organization you are with such as a practice. e.g. Chesterfield Mental Health

Organization/Practice Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Child's Name (First name, Last name initial)

First Name

Last Name

Case/Patient Number (if applicable)

So you can track internally, this will be the number assigned to that individual

Child's Gender

*

Male

Female

Other

Date of Birth

*

Example 1/8/1998

Ethnicity/Race (Choose one or more)

*

We have to track who we are helping for grant purposes

Hispanic/Latino

American Indian/Alaska native

African American

Asian

Caucasian

Native Hawaiian/Pacific Islander

Other

Relationship to child

*

Parent

Guardian

Parent or Guardian Name #1

*

First Name

Last Name

Parent/ Guardian Home Phone

Parent/Guardian Mobile Phone

Parent/Guardian Email

Verify Email

Parent/Guardian Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Psychologist/Caseworker

Reasons for referring this child/family for a psychological evaluation over an intensive clinical assessment:

Indicate what you are applying for

*

You can apply to Beacon Tree for funding for a mental health evaluation or treatment for youth under 21

A psychological assessment/evaluation

Mental health treatment for a child

Both

Statement from the therapist/case worker that the evaluation/treatment is needed

*

This is simply the reason you think the evaluation is needed. Basically, it's the "story"

Does the child have an IEP?

*

Yes

No

Past Evaluations/Treatment History

List past evaluations here if applicable

List the Evaluations/Treatment for this Case

*

List all evaluations you are seeking funding for with commas in between

Purpose of testing or treatment

If this is an evaluation, how will the test results be used?

Timeframe needed:

Provider doing the Evaluation/Assessment/Treatment

Name of the practice and provider

Ballpark Estimated Cost of Services

*

This is just so we know how much to budget for this application. It can be a ballpark. APPLICATIONS WITH NO ESTIMATE WILL NOT BE ACCEPTED

Insurance Information for Child

Name of Insurance Plan

Is this Medicaid?

*

Yes

No

No insurance at this time, check here

No insurance