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Individual Peer Support Referral form

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MANAGER is active?
Field to help Client filtration depending on the user type
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Returned Client?
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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Buck up Field/ This Field is for Autogenerated Recipient No. incase if we need it.
Caregiver Name*
MM slash DD slash YYYY
Second Caregiver
MM slash DD slash YYYY
Address
Region is auto populated based on the county.
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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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Please enter a number greater than or equal to 0.
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Please enter a number greater than or equal to 0.
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Please enter a number greater than or equal to 0.
Which of the following BEST describes the kinship caregiver?*
Is the caregiver a US Citizen or have a Permanent Residency status?*
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This Caregiver's involvement began as an Inquiry.
I wish to create a:*
MM slash DD slash YYYY
Your Affiliation*

Is the family currently involved with Department for Community Based Services (DCBS)?
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MM slash DD slash YYYY

What happens next?

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Add Registration information to the Referral entry By Coordinator?
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

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

How do you describe your gender?

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Which of the following BEST describes you?*
requested to be hidden due to duplicate, on 5/21/2025

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

Community Agency Involvement

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

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.

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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    Active Client?
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    Connection Created?
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    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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    MM slash DD slash YYYY
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    Reason Connection Not Created

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    MM slash DD slash YYYY
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    CONNECTION

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    MM slash DD slash YYYY
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    MM slash DD slash YYYY
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    Terminate this Connection
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    TERMINATION

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    MM slash DD slash YYYY
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    Termination Reason

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    TANF Eligibility

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    ENTRY INFORMATION

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