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Client Referral/Registration Form
Service Recipient No.
Caregiver Name
(Required)
First
Last
Address
Street Address
APT/Box
City
State
ZIP / Postal Code
Phone
(Required)
Preferred Email
In what county does the family reside?
Please Select the Family's County
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
McCracken
McCreary
McLean
Madison
Magoffin
Marion
Marshall
Martin
Mason
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Region
(Required)
This is entered for you based on the county.
I wish to create a:
Please choose one.
Referral for a family to be contacted about the KY-KINS program
Registration for myself to join the KY-KINS program
Referral Date
MM slash DD slash YYYY
Community Agency Involvement:
Is the family involved currently involved with Department for Community Based Services (DCBS)?
Yes
No
Unsure
Please indicate the DCBS County office working with the family.
Please Select the DCBS County Office
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
McCracken
McCreary
McLean
Madison
Magoffin
Marion
Marshall
Martin
Mason
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Individual completing this form:
(Required)
Hidden
2nd Hidden date on original form
MM slash DD slash YYYY
What is your phone number?
What is your email address?
(Required)
Relationship to Referred Client:
Please share any additional pertinent information about the caregiver you are referring to KY-KINS.
What happens next?
Hidden
Add Registration information to the Referral entry By Coordinator?
Yes
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.
End of Referral Information
Registration Date
MM slash DD slash YYYY
So that we can best match you with support services, please tell us a little about yourself.
What is your age?
(Required)
How do you describe your gender?
Female
Male
Other
Which of the following BEST describes you?
(Required)
Relative Caregiver
Fictive Kin Caregiver
Child-Specific Foster Care Relative Care Provider
Other
Which of the following BEST describes how your fictive kin/relative came to be placed with you?
(Required)
Formal Arrangement (The child(ren) was placed with me by CPS)
Informal (The child(ren) was NOT placed with me by CPS)
Relative/Fictive Child(ren) Information:
Please provide the names/ages of the relatives/fictive kin currently in your care.
Click the + at the end of the row to add more children.
Name
Age
Relationship of the child(ren) to you
Add
Remove
In total, how long have you been caring for the relative/fictive kin child(ren) in your home. To answer this question, please think about the child(ren) you have had the LONGEST?
Number of Years
(Required)
Number of Months
(Required)
Number of Weeks
(Required)
Community Agency Involvement
Do the child(ren) in your care currently have an OPEN DCBS case?
(Required)
Yes
No
Who is the DCBS Worker or the DCBS office you are working with ?
(Required)
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.
Please indicate any specific requests or areas you would like assistance from a Peer Supporter, if any
What are you hoping this program can provide for you and your family?
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
Hidden
Program Coordinator Notes
Hidden
Active Client?
Active
Inactive
Hidden
Connection Created?
Yes
No
Hidden
NO CONNECTION
Hidden
Date referral closed without a connection
MM slash DD slash YYYY
Hidden
Reason Connection Not Created
Declined Services
Did not respond to communication efforts
Resided out of pilot region
Case managed by a DCBS office out of pilot region
No longer providing Kinship care
Caregivers are choosing to become foster parents
Caregivers not completing registration requirements for enrollment in the program
Incorrect/Inappropriate referral
Caregiver joined the KIN VIP Support Group program
Other
Hidden
Date Referral Source notified of No Connection (if able)
MM slash DD slash YYYY
Hidden
CONNECTION
Hidden
Connection Start Date
MM slash DD slash YYYY
Hidden
Client Number
Hidden
Peer Supporter Name
Choose Peer Supporter
Rachael Wall
Jessica Adkins
Regina Henderson
George Test Humlong Test
Hidden
Peer Supporter Email
Hidden
Date Referral Source notified if Connection made (if able)
MM slash DD slash YYYY
Hidden
Terminate this Connection
Yes
No
Hidden
TERMINATION
Hidden
Connection End Date
MM slash DD slash YYYY
Hidden
Termination Reason
Per Client Request – Not enough time in schedule to participate
Per Client Request – No longer providing kinship care
Per Client Request – No longer in need of program services
Per Client Request – Child has been reunified with parent
Per Program Staff – Not participating in services
Per Program Staff - Unreachable-not responding to efforts to engage
Other
Hidden
Notes
Hidden
ENTRY INFORMATION
Hidden
Entered By
Hidden
Entered By Email
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