MU PSC RFS - Parenting Group

This Request for Services (RFS) form is specifically for parents interested in attending our Parenting Group (also known as 1-2-3 Magic). Parents qualify for this group if 1) they live in Boone County and 2) their child(ren) is age 2-12. If you are actually requesting services for a youth assessment and/or treatment services, please fill out that RFS here: https://redcap.link/psc_youthrfs

[Office staff] Client Number:

[Office staff/Jenna] What month will client attend Parenting Group?

[Clinic staff only] Name of office support assistant completing this form:

Today's Date:

* must provide value

M-D-Y

Your child's legal last name:

* must provide value

Your child's legal first name:

* must provide value

Your child's preferred name (if different from above):

Gender:

Pronouns:

Race/Ethnicity:

Age:

Date of Birth:

* must provide value

M-D-Y

Please type your name and your relationship to the child:

* must provide value

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What is the best phone number to contact you or leave a voicemail?

* must provide value

What is the best email for us to use when contacting you about an appointment?

* must provide value

Local Street Address:

* must provide value

City (for example, Columbia):

* must provide value

County (for example, Boone):

* must provide value

State:

* must provide value

Zip Code:

* must provide value

What is your current employment status?

Is your child a student?

Yes

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Please describe the concerns that your child needs help with.

* must provide value

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Are you or your child currently experiencing any thoughts of suicide or self-harm?

* must provide value

Yes

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Please briefly describe these thoughts:

* must provide value

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Emergency Contacts & Crisis Resources

If you feel like you cannot keep yourself or others safe, please seek emergency help immediately by calling 911, going to your local emergency room, or using one of the following resources. We offer the following resources in case of emergency:

Organization	Phone Number	Text Number	24/7 Crisis Services?
MU Counseling Center	573-882-6601		Yes
Missouri Crisis Line	1-888-761-4357	HAND to 839-869	Yes
Trans Peer Support Hotline	877-565-8860		Yes
Trevor Project (LGBTQ youth)	866-488-7386	START to 678-678	Yes
National Suicide Prevention Hotline	1-800-273-8255	HOME to 741-741	Yes
Deaf Crisis Line	321-800-3321		Yes
Burrell Behavioal Health Walk-in Clinic (3401 Berrywood Dr. Columbia, MO)	573-777-8300		Monday-Friday, 8am to 5pm
Missouri Psychiatric Center (3 Hospital Dr. Columbia, MO)	573-884-1255		Yes

How did you hear about us (e.g., insurance company, website)?

Are you or your child currently involved in any legal situation, such as a court case, custody battle, or needing a child abuse investigation?

* must provide value

Yes

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What is your insurance company and plan? (If none, put none).

* must provide value

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