Referral for Child and Adolescent Services

Submission ID

Hidden

Internal Request?

Internal transfer
Additional Services Request

Hidden

Was the client accepted for services?

Yes
No
Wait Listed

Hidden

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

Hidden

Name of BHP accepting client

First Last

Hidden

Name of TCM accepting client

First Last

Hidden

Name of CSA accepting client

First Last

Hidden

Notes for Providers

This field will show on the waitlist report; use only for notes we want to share with providers for matching purposes.

Hidden

Admin Only Notes

This 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 Phone

Client Information

Client Name*

First Last

Date of Birth*

Sex as Registered with your Insurance Company

Male
Female

Language Needs

Address*

Street Address Address Line 2 City State ZIP Code

County*

School or Daycare

Insurance Information

Private 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*

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

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*

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 Referral

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

*providers and hospitals please provide the diagnosis

Please indicate the services you are interested in receiving:*

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 photos of the front and back of insurance cards

Drop files here or

Max. file size: 32 MB.

Hidden

Date of initial BHP appointment

Hidden

Date of initial TCM appointment

Hidden

Date of initial CSA appointment

Name

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