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1
Today's Date
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Date
Month
Day
Year
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2
Please enter your name below
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First Name
Last Name
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3
Is this your first time referring to Bluegrass Recovery?
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Yes
No
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4
How did you hear about us?
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Bluegrass Recovery Video
National Treatment, Prevention, and Education Center
Transcend Counseling Services
Department of Corrections
U of L Health (Peace Hospital)
Center for Behavioral Health
Google
Facebook
Louie Connect
Unite Us
Other
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5
Please enter the email address where you want to receive progress reports for this client.
example@example.com
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6
Name
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First Name
Last Name
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7
Phone Number
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Area Code
Phone Number
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8
Email
example@example.com
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9
Please upload the client's Release of Information below (if applicable).
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10
To my knowledge, the referred client does have an active Kentucky Medicaid Plan.
*
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Yes
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11
Referral Reason(s)
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Targeted Case Management
Medication Management
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12
Please include any additional information you want to share about this client below.
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