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    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.
  • This is entered for you based on the county.

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  • Please choose one.
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  • Community Agency Involvement:



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  • What happens next?

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  • 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.







  • Relative/Fictive Child(ren) Information:



  • Click the + at the end of the row to add more children.
    NameAgeRelationship 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?
  • Community Agency Involvement





  • 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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    NO CONNECTION

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    MM slash DD slash YYYY
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    CONNECTION

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    TERMINATION

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    ENTRY INFORMATION

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    FOR FILTTERING

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