Placing a Child

What to do?

When a child needs help, it is often very reassuring to talk to someone. You are welcome to call our office at (573) 588-2191. Normal hours are 9:00 a.m to 4:00 p.m. (Central), Monday through Friday. The form below contains the questions you will be asked if you call. Reading it through before calling may help ease you through the process.

Your situation might make it difficult to reach us by phone. You may fill in the requested information below and send it to us. This may be done by clicking the "submit" button at the bottom of the form or printing it and using regular mail.

What next?

Once the initial information is received, Shiloh's counselor and/or placement coordinator will contact you to discuss placement possibilities. A full placement packet will be sent and pre-placement interview scheduled as needed.

Shiloh Christian Children's Ranch
Box 606
Shelbina, MO 63468
(573) 588-2191

About the Person Inquiring
Name
Relationship to Child
Address
City
State Zip
Daytime Phone
Evening Phone
Email Address
About the Child
First Name
M.I.
Last Name
Sex M F
Age
Born:Yr MoDay
Grade
Address
City
State Zip
Parental Information
Father's Name
Phone
Address
City
State Zip
Mother's Name
Phone
Address
City
State Zip
Child's Background
Check all behaviors that apply:
Runaway Tobacco Alcohol Drugs
Pornography Lying Stealing Sexually Active
Abusive Violent
Involvement with Law Enforcement Problems with School Officials Yes No
Has this child been Physically or Sexually Abused? Yes No
Has this child been Neglected? Yes No
Describe this child's School Performance
Please specify prescription medications currently taking
Additional Information
How did you come to contact Shiloh for Assistance?
Contact Information (If different than Person Inquiring)
Name
Address
City
State Zip
Phone
Email
Fax