KIN VIP Referral Form

KIN-VIP (Kinship – Virtual Interaction Pilot) is a virtual support group for kinship providers. KIN-VIP is a cutting-edge programmatic initiative designed to improve service delivery, support, and foster collective community to Kentucky’s kinship providers.

To refer a kin or fictive-kin caregiver to participate in KIN-VIP, please complete the referral form below.

Caregiver Name*
First Last
Hidden
Date
MM slash DD slash YYYY
Address
Street Address APT/Box City State ZIP / Postal Code
Phone*
Caregiver Email
In what county does the family reside?
Community Agency Involvement:
Is the family involved currently involved with Department for Community Based Services (DCBS)?
Please indicate the DCBS County office working with the family.
Individual completing this form:*
Hidden
Date
MM slash DD slash YYYY
What is your phone number?
What is your email address?*
Relationship to Referred Client:
Please share any additional pertinent information about the caregiver you are referring to KY-KINS.
What happens next?
A KY-KINS staff member will reach out to you within the next five days. In the meantime, if you have any questions, please feel free to contact Sheila Rentfrow or 859 257-4785.

KIN VIP Referral Form

KIN VIP Referral Form

Community Agency Involvement:

What happens next?