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:
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.Format: (000) 000-0000.
Client Insurance Type:
Assessments Requested

Other
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.Format: (000) 000-0000.
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)
Does Referral source have knowledge of current tobacco, alcohol, or drug use by client?
Does referral source have any knowledge of current suicidal or homicidal thoughts or behavior?
Within the last 6 months, has the client received in-patient services in a psychiatric hospital, residential, substance treatment facility, or crisis stabilization unit?
Has the client engaged in violence towards others, made threats of violence, or used weapons against others?
Has the client engaged in self harming behaviors in the past month?
Has the client run away from home in the past 3 months?
Is the client currently experiencing homelessness, housing or rent problems, unemployment, or difficulty paying bills?
If yes to any of the above, please explain:
Is there DCBS Involvement?
Is there CDW (Court Designated Worker) Involvement?
Has there been incarceration in the past 6 months?
File Upload

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

Professional Referral Form

Client Information

Referral Source Information

Client Health/Progress Information