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For Providers

Please answer all of the questions below to make a referral to any of our services.

General Referral

  • Client Contact Information

  • Insurance Information

  • Referring Agency Information

 

If you are requesting a referral for Targeted Case Management services ONLY, please complete the following forms along with the general referral form.

 

Kentucky Determination Criteria Checklist for Serious Mental Illness (SMI)

SMI Checklist
  • Serious Mental Illness (SMI) Checklist

    Relates to KRS 210.005 and 907 KAR 15:060, 15:065, 15:050, and 15:055, and 908 KAR 2:260. The following questions illustrate the criteria that shall be met for an individual to be designated as seriously mentally ill (SMI). In order to designate an individual as SMI, all the criteria in questions 1,2,3,4 shall be met. Please select the following criteria for age, diagnoses, disability and duration.
    Clear evidence of functional impairment in two or more of the following domains.
    One or more of these conditions of duration.

 

Kentucky Checklist for the Identification of Moderate to Severe Substance Use

Kentucky Checklist for Identification of Moderate to Severe Substance Use
  • Substance Use Checklist

    The following questions illustrates the criteria that shall be met for an individual to receive targeted case management for Substance Use Disorder (Moderate, Severe)
    Individual meets criteria for one or more of the specific Substance Use Disorder diagnoses listed below, as designated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.