COGNITIVE CONNECTIONS KY
ABI Waiver Referral & Intake Form
Please complete this form in full to assist with timely review, intake coordination, and service onboarding.
REFERRAL SOURCE INFORMATION
Date of Referral:
-
Month
-
Day
Year
Date
Case Manager Name:
*
Agency Name:
*
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Preferred Contact Method:
Phone
Email
PARTICIPANT INFORMATION
Participant Name:
*
Date of Birth:
-
Month
-
Day
Year
Date
Medicaid Number:
Primary Diagnosis / ABI History:
Guardian / Legal Representative:
Primary Phone Number:
Format: (000) 000-0000.
Current Address:
*
Emergency Contact:
Emergency Contact Phone:
Format: (000) 000-0000.
SERVICES REQUESTED
Counseling Services
Personal Care Services
Reason for Referral:
*
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CLINICAL & FUNCTIONAL INFORMATION
Current Behavioral Concerns:
Current Mental Health Diagnoses:
Known Triggers / Safety Concerns:
Current Medications (if applicable):
Mobility / Physical Assistance Needs:
RISK & SAFETY SCREENING
History of Aggression:
*
Yes
No
History of Elopement:
*
Yes
No
Suicidal Ideation History:
*
Yes
No
Fall Risk:
*
Yes
No
Self-Harm History:
*
Yes
No
24/7 Supervision Needed:
Yes
No
Additional Safety Information:
SERVICE COORDINATION
Preferred Start Date:
Current Living Arrangement:
Independent
Family Home
Residential Placement
Other
Preferred Service Schedule / Availability:
*
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DOCUMENTS INCLUDED
Please upload documents to be reviewed
Map 351
Plan of Care
Psychological / Clinical Assessment
Medication List
Guardianship Documentation
Risk / Crisis Plan
Other
File Upload
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Referring Party Signature:
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