Barrier Submission Form

**Please do not include identifying information in your responses (i.e. birthdates, names, etc.)

What is the System of Care?

We are a collaborative group of youth, parents, and community providers. We work to identify and resolve barriers preventing youth and families from receiving services in youth-serving systems. Our goal is to ensure youth-serving systems help youth be healthy, at home, in school, out of trouble, with friends, and thriving.

A barrier is a problem or block to receiving the services and support you need. Do you know someone who has experienced a barrier or problem while working with youth-serving systems, like child welfare, juvenile justice, intellectual/developmental disabilities, education, early learning, substance use treatment, physical, mental or oral health, or other community services?

If so, then you’ve come to the right place. Please fill out the Barrier Submission Form and tell us about it. Please do not include identifying information or protected health information, such as names, birthdays, health information, etc.

Question Title

* 1. Today's Date:

Click to select a date.

Date

Question Title

* 2. In which county did you experience this barrier? (Select all that apply)

Polk County

Marion County

Other (please specify)

Question Title

* 3. Age of the young person or young people impacted by this barrier (Select all that apply):

0-5 years

6-12 years

13-17 years

18-25

26 years or older

Question Title

* 4. What system or organization were you trying to work with when you had this problem? (Select all that apply)

Department of Human Services (DHS) Self-Sufficiency

DHS Child Welfare or Foster Care

Wraparound

School or Education

Family

Juvenile Justice, Corrections, or Legal System

Law Enforcement, Sheriff, or Police

Mental Health

Substance Use

Oral Health or Dental

Physical Health or Primary Care

Intellectual & Developmental Disabilities

Early Learning

Coordinated Care Organization or Health Plan

I do not know or am unsure

Other (please specify)

Question Title

* 5. Are the organizations selected above (in Question #4) aware of this problem?

Yes, this problem has been discussed with the selected organizations.

No, this problem has not been discussed with the selected organizations.

I do not know if this problem has been discussed with the selected organizations.

Question Title

* 6. What category best describes the problem or barrier?

Access to Care (unable to find care or were denied care for some reason)

Quality of Care (unhappy with the care you or someone else received)

Lack of Collaboration (problems with who does what, problems with collaboration or follow through)

Problems Using Services (too complicated, too many steps, the process gets in the way of helping people)

Policies & Procedure (rules, laws, or policies that get in the way of what you need)

Culturally Unresponsive (mistreated because of culture, language, identity, etc.)

Challenges with Getting Basic Needs Met (transportation, childcare, housing, food insecurity, etc.)

I'm not sure

Other (please specify)

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* 7. Please tell us in your own words what happened. What was the barrier?

Question Title

* 8. Has this happened before or is this the first time?

This has happened 1 or more times before.

This is the first time I know of this happening.

I don't know.

Other (please specify)

Question Title

* 9. What work has been done on this issue already? What has worked well? What has not worked well?

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* 10. Recommendations: What would you like to see happen?

Question Title

* 11. What is your role?

Youth

Parent or Legal Guardian

Family Member

Friend

Advocate for Youth or Families/Youth Partner/Family Partner

Foster Parent

DHS Case Worker

Intellectual/Developmental Disabilities Worker

Mental Health or Substance Use Provider

Physical Health or Oral Health Provider

Law Enforcement or Community Corrections Worker

Care Coordinator or Case Manager

Education or School Staff

Concerned Community Member

Other (please specify)

Question Title

* 12. Which of the following are you interested in? (Select all that apply)

I would like to hear back about what happens with this barrier.

I would like to attend a System of Care meeting to tell the committee about this barrier.

I am interested in learning more about being on a System of Care committee so I can use my voice to advocate for Youth and Families.

Other (please specify)

Question Title

* 13. Please provide your contact information. Sometimes our committees have more questions about barriers. Please provide your name and the best way to contact you. Thank you!

Name

City/Town

Email Address

Phone Number

What Happens After I Submit My Barrier?

Once a Barrier Submission Form is submitted, we will get it to the right Committee. If your barrier cannot be resolved by that committee, it will be given to another. Barriers will spend no longer than 3 months with one committee. The process will follow the rough timeline below.

If you have questions about what's happening with your barrier, please email the System of Care Coordinator, Heather Pascoe, at heather.pascoe@pacificsource.com

**Please note: Not all barriers will be addressed every month and this process is not intended to address urgent or crisis situations. This form does not replace the formal grievance process that exists for providers and system partners. If it looks like another grievance process is needed, we will let you know!

Barrier Submission Form

**Please do not include identifying information in your responses (i.e. birthdates, names, etc.)

Question Title

* 1. Today's Date:

Question Title

* 2. In which county did you experience this barrier? (Select all that apply)

Question Title

* 3. Age of the young person or young people impacted by this barrier (Select all that apply):

Question Title

* 4. What system or organization were you trying to work with when you had this problem? (Select all that apply)

Question Title

* 5. Are the organizations selected above (in Question #4) aware of this problem?

Question Title

* 6. What category best describes the problem or barrier?

Question Title

* 7. Please tell us in your own words what happened. What was the barrier?

Question Title

* 8. Has this happened before or is this the first time?

Question Title

* 9. What work has been done on this issue already? What has worked well? What has not worked well?

Question Title

* 10. Recommendations: What would you like to see happen?

Question Title

* 11. What is your role?

Question Title

* 12. Which of the following are you interested in? (Select all that apply)

Question Title

* 13. Please provide your contact information. Sometimes our committees have more questions about barriers. Please provide your name and the best way to contact you. Thank you!

Question Title

Timeline