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For Providers

Make A Provider Referral:

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.

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.
Patient Name*
First Last
Patient SSN*
1. Age: Is this person aged 18 years or over calculated at the time of service?*
2. Diagnosis (please select applicable diagnosis): Has one or more of the following mental health diagnoses as designated in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders?*
- Delusional Disorder 297.1
- Schizophreniform Disorder 295.40
- Schizophrenia 295.90
- SchizoAffective Disorder 295.70
- Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 298.8
- Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 298.9
- Bipolar I Disorder 296.41, 296.42, 296.43, 296.51, 296.52, 296.53, 296.44, 296.45, 296.46, 296.40, 296.54, 296.55, 296.50
- Bipolar II Disorder 296.89
- Cyclothymic Disorder 301.13
- Other Specified Bipolar and Related Disorder 296.89
- Unspecified Bipolar and Related Disorder 296.80
- Major Depressive Disorder 296.21, 296.31, 296.22, 296.32, 296.23, 296.33, 296.24, 296.34, 296.25, 296.35, 296.20, 296.30
- Persistent Depressive Disorder (Dysthymia) 300.4
- Other Specified Depressive Disorder 311
- Unspecified Depressive Disorder 311
- Posttraumatic Stress Disorder 309.81
3. Disability (Please select domains of impairments):*
- Select All
- Societal/Role Functioning: Functioning in the role most relevant to his/her contribution to society and, in making that contribution, how well the person maintains conduct within societal limits prescribed by laws, rules and strong social mores.
- Interpersonal Functioning: How well the person establishes and maintains personal relationships. Relationships include those made at work and in the family settings as well as those that exist in other settings.
- Daily Living/Personal Care Functioning: How well the person is able to care for him/herself and provide for his/her own needs such as personal hygiene, food, clothing, shelter and transportation. The capabilities covered are mostly those of making reliable arrangements appropriate to the person’s age, gender and culture.
- Physical Functioning: Person’s general physical health, nutrition, strength, abilities/disabilities and illnesses/injuries.
- Cognitive/Intellectual Functioning: Person’s overall thought processes, capacity, style and memory in relation to what is common for the person’s age, gender, and culture. Person’s response to emotional and interpersonal pressures on judgments, beliefs and logical thinking should all be considered in making this rating.
Clear evidence of functional impairment in two or more of the following domains.
4. Duration (Please circle at least one duration condition):*
- Select All
- Clinically significant symptoms of mental illness have persisted in the individual for a continuous period of at least 2 (two) years.
- The individual has been hospitalized for mental illness more than once in the past 2 (two) years.
- There is a history of one or more episodes with marked disability and the illness is expected to continue for a two-year period of time.
One or more of these conditions of duration.
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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)
Patient Name
First Last
Patient SSN
1. Diagnosis (Please circle diagnoses)*
- Alcohol Use Disorder-Moderate 303.90
- Alcohol Use Disorder-Severe 303.90
- Cannabis Use Disorder-Moderate 304.30
- Cannabis Use Disorder-Severe 304.30
- Hallucinogen-Related Disorders
- Phencyclidine Use Disorder-Moderate 304.60
- Phencyclidine Use Disorder-Severe 304.60
- Other Phencyclidine Use Disorder-Moderate 304.50
- Other Phencyclidine Use Disorder-Severe 304.50
- Inhalant Use Disorder-Moderate 304.60
- Inhalant Use Disorder-Severe 304.60
- Opioid Use Disorder-Moderate 304.00
- Opioid Use Disorder-Severe 304.00
- Sedative, Hypnotic, or Anxiolytic Use Disorder-Moderate 304.10
- Sedative, Hypnotic, or Anxiolytic Use Disorder-Severe 304.10
- Amphetamine-type substance-Moderate 304.40
- Cocaine-Moderate 304.20
- Other or unspecified stimulant-Moderate 304.40
- Amphetamine-type substance-Severe 304.40
- Cocaine-Severe 304.20
- Other or unspecified stimulant-Severe 304.40
- Other (or Unknown) Substance-Related Use
- Disorder-Moderate 304.90
- Other (or Unknown) Substance-Related Use Disorder-Severe 304.90
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.
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