RESTkc Family Intake Form

RESTkc Family Intake Form
Thank You for Your Interest in RESTkc !

This form helps us learn more about your child’s medical needs and determine if RESTkc is be a good fit for your family.

RESTkc serves families of children with significant ongoing medical complexity. Eligibility is based on the level of medical caregiving and support your child needs over time, not diagnosis alone.

Please complete this form as fully as you can. If you are unsure about an answer, your best estimate is okay. You may also use your own words anywhere additional context would be helpful.

At this time, RESTkc provides in-home services for families living in Johnson County and Wyandotte County, Kansas, and inpatient services for families receiving acute hospital-based care in the KC metropolitan area.

All fields are optional unless marked required (*).

Section 1 - Basic Information
Child’s Year of Birth
Parent/Caregiver Name(s)
Separate multiple names with a comma
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityStateZip Code
County of Residence

Other

Section 2 - Child’s Medical Needs
What diagnoses has your child received?
In your own words, how would you describe your child’s medical needs?
Which of the following best describe your child’s condition? (Select all that apply)

Section 4 - Medical Specialists
Number of Medical Specialists
Specialties Involved in Child’s Care

Section 5 - Healthcare Utilization (Past 12 Months)
Number of Hospitalizations in the Past 12 Months
Number of Emergency Department Visits in the Past 12 Months
Does your child have ongoing or complex outpatient care
If "yes" to the previous question, please describe (e.g., therapies, infusions, frequent appointments):

Section 8 - Additional Context
What are the most challenging parts of caring for your child’s medical needs?
What kind of support are you hoping to receive from RESTkc?
Is there anything else you would like us to know about your child or family?

Section 9 - Fit & Understanding / Attestation

Before submitting, please confirm the following
Before submitting, please confirm the following:
Primary Care Provider Name
Primary Care Provider Clinic/Practice
Primary Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Should be Empty: