Client Referral/Registration Form

"*" indicates required fields

Individual Peer Support Referral form

Service Recipient No.

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MANAGER is active?

Field to help Client filtration depending on the user type

Active

Inactive

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Returned Client?

YES

This field for rejoined Clients, if you Marked this field YES, you need to update the Client Service Recipient No. above. **** for Help Ask Ayla

Caregiver Name*

First Last

Caregiver DOB

Second Caregiver

First Last

Second Caregiver DOB

Address

Street Address APT/Box City State ZIP / Postal Code

In what county does the family reside?*

Region*

Region is auto populated based on the county.

Phone*

Second Caregiver/Alternative Phone number

Preferred Email

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Relative/Fictive Child(ren) Information:

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Number of Years

Please enter a number greater than or equal to 0.

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Number of Months

Please enter a number greater than or equal to 0.

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Number of Weeks

Please enter a number greater than or equal to 0.

Which of the following BEST describes the kinship caregiver?*

Relative Caregiver (related to the child by birth, marriage, or adoption)

Fictive Kin Caregiver (unrelated to the child, but has a significant relationship with the child or the family if the child is under the age of 1)

What type of kinship arrangement does the family have?*

Is the caregiver a US Citizen or have a Permanent Residency status?*

Yes

Unsure

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This Caregiver's involvement began as an Inquiry.

YES

I wish to create a:*

Referral for a family to be contacted about the KY-KINS program

Registration for myself to join the KY-KINS program

Your Affiliation*

DCBS

Family Friend

FRYSCKy

Other Educational Programs

Mental Health Agencies

Community Organization

Individual

Kinship Navigator

Other

What happens next?

End of Referral Information

So that we can best match you with support services, please tell us a little about yourself.

Which of the following BEST describes how your relative or fictive kin child(ren) came to reside with you?*

Formal Arrangement (The child(ren) was placed with me by CPS)

Informal (The child(ren) was NOT placed with me by CPS)

Community Agency Involvement

Do the child(ren) in your care currently have an OPEN DCBS case?*

Yes

Request for Services

KY-KINS Peer Support program provides a personal, one on one, mentoring services to assist Relative/Fictive Kin caregivers in providing the best care for the children they are raising at no cost. Through these services, Caregivers will have frequent contacts with their Peer Supporter each week designed to help Caregivers navigate resources, network with needed professionals and services, and receive support designed to aid the Caregiver in providing a stable home for relative/fictive kin children.

By submitting this form electronically, you are electing to participate in the KY-KINS Peer Support Program.

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.

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Kinship Staff use Only

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Program Coordinator Notes

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Active Client?

Active

Inactive

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Connection Created?

Yes

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LMS Participant ID For this Caregiver/ Client

Unique LMS Participant ID to track their activities in the LMS., get that ID from their LMS account. and add it here.

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NO CONNECTION

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Reason Connection Not Created

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CONNECTION

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Terminate this Connection

Yes

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TERMINATION

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Notes

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TANF Eligibility

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Individual Peer Support Referral form

Relative/Fictive Child(ren) Information:

What happens next?

End of Referral Information

So that we can best match you with support services, please tell us a little about yourself.

Community Agency Involvement

Request for Services

What happens next?

Kinship Staff use Only

NO CONNECTION

CONNECTION

TERMINATION

TANF Eligibility

ENTRY INFORMATION