Referral for Child and Adolescent Services

Referred By:

Referrer Email*

Referrer Name*

First Last

Relationship to client*

Phone

Client Information

Client Name*

First Last

Date of Birth*

Gender

Male
Female

Language Needs

Address*

Street Address Address Line 2 City State ZIP Code

County*

School or Daycare

Insurance Information

Does the client have Kentucky Medicaid?*

Yes
No

Medicaid Number*

Name of Managed Care Company*

Member Identification Number*

Is the client covered by Medicare?*

Yes
No

Transformations providers are not currently contracted to provide Medicare services.

Does the client have commercial insurance coverage?*

Yes
No

Name of Primary Insurance Company*

Member Identification Number*

Primary Insured's Name*

Primary Insured's Birthdate*

Does the client have a secondary commercial insurance coverage?

Yes
No

Does the client have two insurance plans?*

Yes
No

Transformations is not accepting clients covered by two insurance plans.

Name of Secondary Insurance Company

Member Identification Number*

Secondary Insured's Birthdate*

Secondary Insured's Name*

Guardian Information

Name*

First Last

Relationship to client*

Is the guardian address different than the client?*

yes
no

Address*

Street Address Address Line 2 City State ZIP Code

Guardian Phone*

Is the child in DCBS custody?*

Yes
No

Placement/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

Reason for Referral

Please tell us about your concerns and how we may help.

*providers and hospitals please provide the diagnosis

Please indicate the service you are interested in receiving:*

Individual and Family Counseling
Targeted Case Management
Student Intern Services
Community Support Services
Group Therapy
I don't know yet, I would like to talk with someone first

Please indicate any services the child is currently receiving:

Inpatient psychiatric hospitalization
Intensive out-patient therapy
Case Management Services
Medication Therapy
Therapeutic Foster Care
Other

Other Services:*

Is this referral for a follow-up to a mental health or chemical dependency hospitalization?

Yes
No

What is the date of the discharge from the hospsital?

Some of our home-based providers have allergies. Please select if the following are in you home.

Dog(s)
Cats(s)
Bird(s)
Cigarette smoking

Please tell us the days and times you are available to meet for services

Are you requesting a specific provider?

Yes
No

What is the name of the provider you are requesting to provide the services?

Attach Files or Documents

Drop files here or

Was the client accepted for services?

Yes
No
Wait Listed

Status 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

Name of BHP accepting client

First Last

Date of initial BHP appointment

Name of TCM accepting client

First Last

Date of initial TCM appointment

Comments

Submission ID

Name

This field is for validation purposes and should be left unchanged.