Initial referrals for youth needing placement in a Kelley Juvenile Justice Resources’ placement can be referred by contacting the KJJR facility or the Corporate Compliance & Quality Assurance Officer.  

Contact Information:

In order for a youth to be placed at a KJJR placement, the placing agency must provide specific information related to billing. The information must be received before placement arrangements can be made with a specific program. 

Once the initial referral information is received and the youth is placed on the Referral List, placement arrangements will be coordinated.  If the appropriate KJJR placement is full, the youth will be placed on the KJJR Waiting List.  Youth will remain on the KJJR Waiting List until bed space becomes available or until the bed is no longer needed.  Please follow the instructions below for all youth needing placed at a KJJR placement.

Steps for Referral Process:

1. Contact the KJJR facility’s Intake Coordinator or KJJR Corporate Compliance & Quality Assurance Officer with initial referral information and access the Referral Packet here.

2. Submit at least the following items for placement consideration:

• KJJR Placement Assessment **
• Provider Placement Agreement (P.A.)
• Medical Card
• Medical Consent (with current Notary Stamp)
• Authorization for Release of Information (SRS Form)
• Journal Entry Authorizing Placement (Secure Care Placement=Required before acceptance/admission)
• PRTF Screen (If needing temporary bed awaiting PRTF placement)

• Medical History Form **
• Case Manager Survey **
• Enhanced Program Participation Release**
• Informed Consent for Services **
• Emergency Intervention (Restrictive Behavioral Intervention) Informed Consent **
• Property Liability Release **
• Request for Student Grades **
• Previous Placement History **
• UA Agreement **
• Youth Contact List **
• Kan Be Healthy Screening (most current)
• Immunization Records
• Dental Records
• Copy of JJA/Placing Agency Case Plan
• School Records/IEP
• Drivers License or Photo Identification
• Social Security Card (copy)
• Birth Certificate (copy)
• Release from High School (GED Preparation)

** Paperwork accessible on our website here.
After submission of the above items, a KJJR Representative will contact you to coordinate an arrival date and time for accepted referrals for the appropriate placement.

Your submission of a Referral Packet “DOES NOT”
guarantee acceptance or admission into a KJJR placement.

Thank you for your time and cooperation

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CMKJJR :: 2600 SE 23rd Street; P.O. Box 5555; Topeka KS, 66605 :: Phone: 785.232.7774 Fax: 785.232.7776

© 2007 Clarence M. Kelley Juvenile Justice Resources