Client Referral Form

Substance Abuse & Mental Health Services

Professional Referral Form

Note: A PDF copy of this referral form will be emailed to you once the form has been submitted.
Please select your referral form preference:*

Shortened Referral FormDetailed Referral Form w/ File Upload
Referral Date*

MonthDayYear
Date

Professional Referral Form

Please fill out this form, you may contact our office(s) if you have any questions.
Client Information
Client Name*

First NameLast Name
Client Date of Birth (DOB)*

MonthDayYear
Date
Client Social Security Number*
Client Phone Number*
Please enter a valid phone number.
Client Insurance Type:*

MedicareMedicaidCommercialSelf-PayNo Insurance
Assessments Requested*

Substance AbuseMental HealthOther
Referral Source Information
Referring Agency*
DCBS/P&P/Drug Court/etc..
Referring Agency County*
Please select your Kentucky County
Referring Agency Contact*

First NameLast Name
Referral Contact Phone Number*
Please enter a valid phone number.
Referral Contact Email Address*
example@example.com
Referring Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Client Health/Progress Information
Reason for Referral/Presenting Problem(s)*
Is there a DSM or ICD-10 Behavioral Health Diagnosis? (examples: Depression, Anxiety, ADHD, Bipolar)*

YesNo
Does Referral source have knowledge of current tobacco, alcohol, or drug use by client?*

YesNo
Does referral source have any knowledge of current suicidal or homicidal thoughts or behavior?*

YesNo
Within the last 6 months, has the client received in-patient services in a psychiatric hospital, residential, substance treatment facility, or crisis stabilization unit?*

YesNo
Has the client engaged in violence towards others, made threats of violence, or used weapons against others?*

YesNo
Has the client engaged in self harming behaviors in the past month?*

YesNo
Has the client run away from home in the past 3 months?*

YesNo
Is the client currently experiencing homelessness, housing or rent problems, unemployment, or difficulty paying bills?*

YesNo
If yes to any of the above, please explain:*
Is there DCBS Involvement?*

YesNo
Is there CDW (Court Designated Worker) Involvement?*

YesNo
Has there been incarceration in the past 6 months?*

YesNo
Does the client require randomized drug testing (CommonHealth Court Club)*

YesNo
File Upload

Court Orders, Release of Information, Case Plans, Etc...
Cancelof
Should be Empty:

Professional Referral Form

Client Information

Referral Source Information

Client Health/Progress Information