Make a Referral Today's Date* Name of Individual Being Referred* First Last Date of Birth* Is the individual you are referring 18 or older?*YesNoGuardian Name(s)With whom does the client reside? First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneGender/Sex* Female Male Other Insurance or Fee For Service* Fee for Service--No Insurance Being Used Kentucky Medicaid Passport Humana Care Source Anthem Medicaid Anthem Blue Cross/Blue Shield Aetna Aetna Better Health of Kentucky Wellcare Value Options Humana Cigna UMR United Health Care Tricare Optum American Behavioral Champ Va Other (Please list in next session) Any additional comments about insurance or payment?DCBS Involvement?YesNoCase Worker First Last Judge's Name (Please write None if there is no Judge involved)*SchoolTeacher First Last GradeReason For Referral(please include any specific behavioral or emotional concerns)Services Requested Individual Therapy Group Therapy Family Therapy Parent Child Interactional Therapy (PCIT) Couples Therapy Case Management Mental Health Assessment/Psychosocial Assessment Substance Abuse Assessment Parenting Classes Co-Parenting Program Anger Management Dialectical Behavioral Therapy (DBT) Batterers Intervention Program (BIP) Women Who Use Force Group Program Incredible Years Parenting Program Name of Person Making Referral* First Last How do you know the person being referred?* I'm Referring Myself I'm a Friend or Family Member I'm a professional working with this person AgencyPhoneEmail Is Gaurdian aware of the referral and expecting a call?YesNoWill you be faxing additional information to Brighter Futures Counseling in regards to this referral? Examples: Prevention Plan/Case Plan, EPO/DVO, Court Orders, Drug Screens, etc. Our fax # is: 270-982-9293*YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.