Client Referral/Registration Form

Service Recipient No.
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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
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Copy the Autogenerated Recipient No. here
Buck up Field/ This Field is for Autogenerated Recipient No. incase if we need it.
Caregiver Name(Required)
First Last
Second Caregiver Name (Optional)
First Last
Address
Street Address APT/Box City State ZIP / Postal Code
Phone(Required)
Preferred Email
In what county does the family reside?
Region(Required)
This is entered for you based on the county.
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This Caregiver's involvement began as an Inquiry.
- YES
- NO
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(Required)
MM slash DD slash YYYY
Your Affiliation(Required)
- DCBS
- Family Friend
- FRYSCKy
- Other Educational Programs
- Mental Health Agencies
- Community Organization
- Individual
Please Enter your Educational Program Name(Required)
Please Enter your Mental Health Agency Name(Required)
Please Enter your Community Organization Name(Required)
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.
Individual completing this form:(Required)
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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?
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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(Required)
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
Which of the following BEST describes you?(Required)
- Relative Caregiver
- Fictive Kin Caregiver
- Child-Specific Foster Care Relative Care Provider
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
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
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Program Coordinator Notes
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Active Client?
- Active
- Inactive
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Connection Created?
- Yes
- No
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NO CONNECTION
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Date referral closed without a connection
MM slash DD slash YYYY
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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
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Date Referral Source notified of No Connection (if able)
MM slash DD slash YYYY
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CONNECTION
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Connection Start Date
MM slash DD slash YYYY
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Peer Supporter Name
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Peer Supporter Email
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Date Referral Source notified if Connection made (if able)
MM slash DD slash YYYY
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Terminate this Connection
- Yes
- No
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TERMINATION
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Connection End Date
MM slash DD slash YYYY
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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
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Notes
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ENTRY INFORMATION
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Entered By
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Entered By Email
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USER ROLE
FOR FILTTERING

Name	Age	Relationship of the child(ren) to you

Community Agency Involvement:

What happens next?

End of Referral Information

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

Relative/Fictive Child(ren) Information:

Community Agency Involvement

Request for Services

What happens next?

Kinship Staff use Only

NO CONNECTION

CONNECTION

TERMINATION

ENTRY INFORMATION