Additional Service Request Additional Services Request Use this form to request additional providers to an already existing client or to transfer a client to a new provider. Do not use this form for new client referrals.Referred By:HiddenReferrer Email* Referrer Name* First Last HiddenRelationship to client* HiddenPhoneClient InformationClient Name* First Last Age of ClientHiddenDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Language Needs HiddenAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County School or Daycare HiddenInsurance InformationDoes the client have Kentucky Medicaid?* Yes No HiddenMedicaid Number Name of Managed Care CompanySelect OneAetna Better Health of KentuckyAnthem MedicaidHumana MedicaidWellcareMedicaid OnlyPassportHiddenMember Identification Number HiddenIs the client covered by Medicare? Yes No Transformations providers are not currently contracted to provide Medicare Services. HiddenTransformations providers are not currently contracted to provide Medicare services. Does the client have commercial insurance coverage?* Yes No Name of Primary Insurance Company* HiddenMember Identification Number* HiddenPrimary Insured's Name HiddenPrimary Insured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenDoes the client have a secondary commercial insurance coverage? Yes No HiddenDoes the client have two insurance plans? Yes No Transformations is not accepting clients covered by two insurance plans. Name of Secondary Insurance Company HiddenMember Identification Number HiddenSecondary Insured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenSecondary Insured's Name HiddenGuardian InformationHiddenName* First Last HiddenRelationship to client HiddenIs the guardian address different than the client? yes no HiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenGuardian PhoneHiddenGuardian Email Address HiddenIs the child in DCBS custody? Yes No HiddenPlacement/Please select all that apply* Lives with parent(s) Lives with extended family Foster care Therapeutic Foster Care JCYC Independent Living Currently Hospitalized Home but currently attending a Partial Hospitalization Program Services RequestedSelect the Services Requested Targeted Case Management (TCM) Community Support Associate Services (CSA) Behavioral Health Professional (BHP) Is this a request to transfer a case? Yes No HiddenComments*providers and hospitals please provide the diagnosisHiddenPlease indicate the services you are interested in receiving: Individual and Family Counseling Targeted Case Management Community Support Services Telehealth In-person services In-home services In-office services Group Therapy I don't know yet, I would like to talk with someone first Type of visit Telehealth In-person services In-home services In-office services HiddenPlease indicate any services the child is currently receiving: Inpatient psychiatric hospitalization Intensive out-patient therapy Case Management Services Medication Therapy Therapeutic Foster Care Other HiddenOther Services: HiddenIs this referral for a follow-up to a mental health or chemical dependency hospitalization? Yes No HiddenWhat is the date of the discharge from the hospsital? MM slash DD slash YYYY HiddenSome of our home-based providers have allergies. Please select if the following are in you home. Dog(s) Cats(s) Bird(s) Cigarette smoking HiddenPlease tell us the days and times you are available to meet for servicesAre you requesting a specific provider? Yes No What is the name of the provider you are requesting to provide the services?CommentsHiddenAttach photos of the front and back of insurance cards Drop files here or Select files Max. file size: 32 MB. HiddenWas the client accepted for services? Yes No Wait Listed HiddenStatus of Denial of Services Client was referred to another provider or agency Cllient refused services Client did not respond to offer of services Client was out of service areas No available provider Agency does not accept client’s insurance No active insurance Client already had a provider in place HiddenName of BHP accepting client First Last HiddenDate Assigned to BHP MM slash DD slash YYYY HiddenDate of initial BHP appointment MM slash DD slash YYYY HiddenName of TCM accepting client First Last HiddenDate Assigned to TCM MM slash DD slash YYYY HiddenDate of initial TCM appointment MM slash DD slash YYYY HiddenName of CSA accepting client First Last HiddenDate Assigned to CSA MM slash DD slash YYYY HiddenDate of initial CSA appointment MM slash DD slash YYYY HiddenCommentsSubmission IDPhoneThis field is for validation purposes and should be left unchanged.