Client Referral/Registration Form

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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

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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*

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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Please provide the names/ages of the relatives/fictive kin currently in caregiver's care.

Click the + at the end of the row to add more children.

Name

Date of Birth

Relationship of the child(ren) to caregiver

Biological Mother Name

Biological Mother Date Of Birth

Biological Father Name

Biological Father Date Of Birth

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?

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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

Referral Date*

Your Affiliation*

DCBS

Family Friend

FRYSCKy

Other Educational Programs

Mental Health Agencies

Community Organization

Individual

Kinship Navigator

Other

Please Enter your Educational Program Name*

Please Enter your Mental Health Agency Name*

Please Enter your Community Organization Name*

Is the family currently involved with Department for Community Based Services (DCBS)?

Yes

Unsure

Please indicate the DCBS County office working with the family.*

Individual completing this form:*

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2nd Hidden date on original form

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?

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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*

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

What is your age?*

How do you describe your gender?

Female

Male

Other

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Which of the following BEST describes you?*

requested to be hidden due to duplicate, on 5/21/2025

Relative Caregiver

Fictive Kin Caregiver

Child-Specific Foster Care Relative Care Provider

Other

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)

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TANF eligibility verified by:

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CHFS/DCBS title:

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Date of verification:

Community Agency Involvement

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

Yes

Who is the DCBS Worker or the DCBS office you are working with ?*

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.

Attach File

Drop files here or

Accepted file types: (doc, docx, pdf, xls, xlsx, txt), Max. file size: 5 MB.

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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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Date referral closed without a connection

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Reason Connection Not Created

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Date Referral Source notified of No Connection (if able)

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CONNECTION

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Connection Start Date

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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)

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Terminate this Connection

Yes

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TERMINATION

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Connection End Date

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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

Other

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Notes

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TANF Eligibility

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ENTRY INFORMATION

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Entered By

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Entered By Email