Make a Referral Is the individual you are referring 18 or over? Or is this for family therapy?*YesNoImportant!!! Unfortunately, our office is no longer providing adult therapy services. We will continue seeing children, adolescents, and families. If you need adult, mental health, or substance abuse services, please go here.Today's Date* Date Format: MM slash DD slash YYYY Name of Individual Being Referred* First Last Date of Birth* Date Format: MM slash DD slash YYYY Guardian 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 Mental Health Assessment/Psychosocial Assessment Parent Child Interactional Therapy (PCIT) 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 Guardian 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