KIN-VIP Referral – KINSHIP Portal

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MANAGER is active?
- Active
- Inactive
Caregiver Name*
First Last
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Date
MM slash DD slash YYYY
Address
Street Address APT/Box City State ZIP Code
Caregiver Email
Phone*
In what county does the family reside?
Community Agency Involvement:
Is the family involved currently involved with Department for Community Based Services (DCBS)?
Please indicate the DCBS County office working with the family.
Individual completing this form:*
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What is your phone number?
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Date
MM slash DD slash YYYY
What is your email address?*
Relationship to Referred Client:
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Which of the following BEST describes the kinship caregiver? (Required)*
- Relative Caregiver (related to the child by birth, marriage, or adoption)hoice
- 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)
Please select the group topic(s) you are interested in:
- Kinship Care Group with Mary Jo-A great place for any kinship caregiver to ask questions and get resources. Meets each month on the second Thursday of every month at 7 pm EST
- Families Impacted by Substance Use- (for caregivers who are coping with a family member’s substance use). Meets twice per month on Tuesdays.
- Dealing with Loss- for those coping with the loss of a person, situation, or relationship. Meets twice per month on Wednesdays.
- Building Family Connections- for those who would like support in managing family relationships as a kinship caregiver. Meets twice per month on Tuesdays.
- Grandparent’s Connection-a place for grandparents to connect, talk, and even do fun projects together. Two opportunities to meet on the 1st and 3rd Mondays at 12 pm EST
- Tweens & Teens- for caregivers caring for kinship children 8 and older. PILOT GROUP/INCENTIVE. Meets weekly on Mondays.
- Fictive Kin 101- for caregivers who are fictive kin, or those who are not related to the child. PILOT GROUP/INCENTIVE. Meets weekly on Thursdays. Text Field for open entry.
- Relatives Raising Kin-two opportunities to meet on the 1st and 3rd Wednesdays each month at 12 pm EST
- Parenting Challenges-two opportunities to meet on the 2nd and 4th Thursdays each month at 12 pm EST
- Other
If you are interested in a topic not listed, please list a topic you would be interested in attending
Please share any additional pertinent information about the caregiver you are referring to KY-KINS.
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Attach File
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Accepted file types: (doc, docx, pdf, xls, xlsx, txt), Max. file size: 5 MB.
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Needs Assessment

Client Name Actions

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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.

Relative/Fictive Kin Group Support Referral Form (KIN VIP)

Community Agency Involvement:

What happens next?