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Relative/Fictive Kin Group Support Referral Form (KIN VIP)
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MANAGER is active?
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Caregiver Name
*
First
Last
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Date
MM slash DD slash YYYY
Address
Street Address
APT/Box
City
Alabama
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American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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New York
North Carolina
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Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Caregiver Email
Phone
*
In what county does the family reside?
select
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
McCracken
McCreary
McLean
Madison
Magoffin
Marion
Marshall
Martin
Mason
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Community Agency Involvement:
Is the family involved currently involved with Department for Community Based Services (DCBS)?
Click to Select
Yes
No
Please indicate the DCBS County office working with the family.
select
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
McCracken
McCreary
McLean
Madison
Magoffin
Marion
Marshall
Martin
Mason
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Individual completing this form:
*
What is your phone number?
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Date
MM slash DD slash YYYY
What is your email address?
*
Relationship to Referred Client:
Which of the following BEST describes the kinship caregiver? (Required)
*
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)
Please select the group topic(s) you are interested in:
The Gathering Spot, a drop in spot to get questions answered and locate resources-meets every Tuesday at 12 pm EST
Kinship Care Group with Mary Jo-A wonderful community of caregivers who share experiences and offer one another support. 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-a new group offering support for caregivers raising a relative’s child: two opportunities to meet on the 1st and 3rd Wednesdays each month at 12 pm EST
Parenting Challenges-this group offers practical parenting suggestions including managing difficult behaviors: 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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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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