Case Manager Request Form

1

Today's Date* This field is required.

Date

2

Please enter your name below* This field is required.

First Name

Last Name

3

Is this your first time referring to Bluegrass Recovery?* This field is required.

Yes

No

5

Please enter the email address where you want to receive progress reports for this client.

example@example.com

6

Name* This field is required.

First Name

Last Name

7

Phone Number* This field is required.

Area Code

Phone Number

8

Email

example@example.com

9

Please upload the client's Release of Information below (if applicable).* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

10

To my knowledge, the referred client does have an active Kentucky Medicaid Plan.* This field is required.

Yes

11

Referral Reason(s)* This field is required.

Targeted Case Management

Medication Management

12

Please include any additional information you want to share about this client below.