Kaylyn's House of Joy
Please fill our form below with as much information as possible, with truth, and to the best of your ability. Any questions, comments, or concerns, please call us at 502-509-3885 or email: Kaylynsjoyhouse@gmail.com.
Information about Person Completing Referral
Name
*
First Name
Last Name
Company/Organization (if related, put "Family." If filling for out for yourself put "SELF")
*
Title/Position/Relationship
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the referred individual aware of this Referral?
Yes
No
Individual Information
Name
*
First Name
Last Name
Preferred Name/Nickname
Date of Birth
*
-
Month
-
Day
Year
Email
example@example.com
Social Security Number
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Way of Communication
Text
Email
Phone Call
Best Time of Day to Call/Text
Morning (9am-12pm)
Afternoon (12pm-3pm)
Evening (3pm-6pm)
Address or Most Recent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Biological Gender
*
Male
Female
Intersex
Prefer not to say
Gender Identity
Male (he/him)
Female (she/her)
Transgender (they/them)
Non-Binary (they/them)
Prefer not to say
Type of Services Needed
*
Female Transitional Housing
Mental Health Services ONLY
Male Transitional Housing
Mental Health Clubhouse & Support
Select all applicable challenges below for the Individual referred (check all that apply)
*
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Specify service Individual is considering
*
Case Management (CM)
Family Therapy (Mental Health ONLY)
Group Therapy (Mental Health ONLY)
Individual Therapy (Mental Health ONLY)
Intensive Case Management (ICM)
Medication Case Management
Peer Supports or Community Support
Psychosocial Rehabilitation (PSR)
Psychosocial Rehabilitation - Individual (PSRI)
Psychiatric Treatment (needs secondary service)
Supported Employment (Mental Health ONLY)**
Alcohol, Drugs, and Substance Use services (Addiction, Intervention, and Prevention)
Reason for Referral
*
Past/ Current Medications
Does participant have insurance?
*
Yes
No
Not Sure
Participants Insurance
Wellcare
Passport
Anthem
United Healthcare
Humana
Aetna
Other (Please specify)
Insurance Policy Number:
Individual's Emergency Contact Name and Phone
Relationship to Individual
Do we have permission to contact your Emergency Contact?
Yes
No
Please take a photo of your ID card. If no ID card available, please send a headshot of individual.
*
Please take a photo of your Medicaid card if available.
Is there any other information we need to know about individual or that the individual would like us to know when considering them for our program and organization?
By signing this form, I am confirming that the information listed above is true and correct to best of my knowledge. I understand that any purposeful misinformation will subject individual to investigation causing individual to be dismissed and not considered from our organization and its programs.
*
Please verify that you are human
*
Submit
Should be Empty: