For Providers

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

General Referral

Client Contact Information
Client Name*
First Middle Last
Guardian Name (if applicable)
First Last
Date of Birth*
Gender*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Social Security #*
Insurance Information
Insurance
Policy or ID #
Group # (if applicable)
Referring Agency Information
Agency*
Agency Contact
First Last
Phone
Email
Relationship to Patient
Preferred Form of Return Communication
Reason for Referral*
Priority of Return Communication*
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If you are requesting a referral for Targeted Case Management services ONLY, please complete the following forms along with the general referral form.

For Providers

General Referral

Client Contact Information

Insurance Information

Referring Agency Information

Kentucky Determination Criteria Checklist for Serious Mental Illness (SMI)

Serious Mental Illness (SMI) Checklist

Kentucky Checklist for the Identification of Moderate to Severe Substance Use

Substance Use Checklist