Referral for Child and Adolescent Services Submission IDHiddenInternal Request? Internal transfer Additional Services Request 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 HiddenName of TCM accepting client First Last HiddenName of CSA accepting client First Last HiddenNotes for ProvidersThis field will show on the waitlist report; use only for notes we want to share with providers for matching purposes.HiddenAdmin Only NotesThis field is for the Intake Coordinator to add notes for closure.Anyone may complete a referral form; this does not need to be completed by a doctor's office or specialist.Your Email* Your Name* First Last Your Relationship to Client* Your PhoneClient InformationClient Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Language Needs Address* 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 Insurance InformationPrivate Pay I do not want to bill an insurance plan for services; I will pay the private pay rate for services. Does the client have Kentucky Medicaid?* Yes No Medicaid Number* Name of Managed Care Company*Select OneAetna Better Health of KentuckyAnthem MedicaidHumana MedicaidUnited Healthcare MedicaidWellcareMedicaid OnlyPassportMember 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*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the client have a secondary commercial insurance coverage? Yes No Does the client have two insurance plans?* Yes No Name of Secondary Insurance Company Member Identification Number* Secondary Insured's Birthdate*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insured's Name* Guardian InformationName* First Last Relationship to client* Is the guardian address different than the client?* yes no Address* 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 Guardian Phone*Guardian Email Address* Is the child in DCBS custody?* Yes No Foster Parent Name* First Last Foster Parent Phone*Foster Parent Email Address* 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 ReferralPlease tell us about your concerns and how we may help.*providers and hospitals please provide the diagnosisPlease 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 In-school 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? MM slash DD slash YYYY 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 servicesAre you requesting a specific provider? Yes No What is the name of the provider you are requesting to provide the services?Attach photos of the front and back of insurance cards Drop files here or Select files Max. file size: 32 MB. HiddenDate of initial BHP appointment MM slash DD slash YYYY HiddenDate of initial TCM appointment MM slash DD slash YYYY HiddenDate of initial CSA appointment MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.