Barrier Submission Form - System of Care of Linn, Benton and Lincoln

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Please do not include Protected Health Information on this form. This form allows you to describe a barrier or block to receiving services or supports for yourself or a young person in your community. To submit this form, click the blue SUBMIT button at the end of the page.

Date?

YYYY

County affected by the barrier:

Linn County

Benton County

Lincoln County

Other

County

Age of young person affected by the barrier:

0-5

6-11

12-18

above 18

Other

Age

Type of Barrier (check all that apply):

Services and Supports (access, setting, location, quality, gaps and funding)

Policies and Procedures (system or agency specific)

Roles and Responsibilities (who does what)

Cultural and Linguistic Competence

State and Federal Rules (FERPA, HIPAA, mandates, laws, policies)

System Collaboration (lack of coordination between systems or agencies)

Engagement (family, community or young person)

Team Meetings Serving Youth and Families (process, protocol and functioning)

Housing Instability

Transportation

Childcare

Food Insecurity

Waitlist for Services

Insurance

Other:

The barrier is related to the following system (check all that apply):

Education

Intellectual/Developmental Disabilities

Juvenile Department

Child Welfare

Foster Care

Behavioral Health

Physical or Dental Health

Wraparound

Substance Use Treatment

Other

Description of barrier (two or more sentences):

Recommendation (please include suggestions on how to overcome barrier):

Your name (optional):

Your email or phone number (optional):

Submit

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