Referral for Adult Services - Transformations LLC

Submission ID

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Internal request?

Internal Transfer
Additional Services Request

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Was client accepted for services?

Yes
No
Client was placed on a 30 day wait list

Hidden

Status of denied referral

Client was referred to another provider/agency
Client refused services
Client did not respond to offer of services
Client was out of service area
No provider available
Agency does not accept client's insurance
No active insurance
Client already had a provider in place

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BHP Accepting Case

Hidden

Notes for Providers

This field will show on the waitlist report; use only for notes we want to share with providers for matching purposes.

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Admin Only Notes

This field is for the Intake Coordinator to add notes for closure.

Anyone may complete a referral form for themself or another person; this form does not need to be completed by a doctor's office or specialist.

Your Email*

Your Name*

First Last

Your Relationship to Client*

Your Phone

Client Information

Client Name*

First Last

Date of Birth*

Sex as Registered with Insurance Company

Male
Female

Language Needs

Address*

Street Address Address Line 2 City State ZIP Code

County*

Email*

Phone*

Insurance Information

Private Pay

I do not want to bill an insurance plan for services; I will pay the private pay rate for services.

Does the client have Kentucky Medicaid?*

Yes
No

Medicaid Number*

Name of Managed Care Company*

Member Identification Number*

Is the client covered by Medicare?*

Yes
No

Name of Medicare Plan

Member Identification Number*

Does the client have commercial insurance coverage?*

Yes
No

Name of Primary Insurance Company*

Member Identification Number*

Primary Insured's Name if other than Client

Primary Insured's Birthdate*

Does the client have a secondary commercial insurance coverage?

Yes
No

Name of Secondary Insurance Company

Member Identification Number*

Secondary Insured's Name if other than Client

Secondary Insured's Birthdate

Is the client covered by two insurance plans?*

Yes
No

Guardian Information

Does the client have a legal guardian?*

Yes
No

Name

First Last

Relationship to client

Phone

Is the guardian's address different than the client's address?

yes
no

Address

Street Address Address Line 2 City State ZIP Code

Reason for Referral

Please tell us about your concerns and how we may help.

*providers and hospitals please provide the diagnosis

Please indicate the services you are interested in receiving:*

Individual Counseling
Couples Counseling
Family Therapy
Community Support
Telehealth
In-person services
In-home services
In-office services
I don't know yet, I would like to talk with someone first

Please indicate any services the client is currently receiving:

Inpatient psychiatric hospitalization
Intensive out-patient therapy
Case Management Services
Medication Therapy
Other

Other Services:*

Is this referral a follow up to a discharge from a mental health or chemical dependency hospitalization?

Yes
No

What is the date of the discharge from the hospital

Some of our home-based therapists have allergies. Please mark if any of the following are in your home.

Dog(s)
Cat(s)
Bird(s)
Cigarette smoking

Please tell us the days and times you are available to meet for services

Do you want a specific provider for your services?

Yes
No

What is the name of the provider you are requesting?

Attach photos of front and back of insurance cards

Drop files here or

Max. file size: 32 MB.

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Date of initial BHP appointment

Hidden

TCM Accepting Case

Hidden

Date of TCM appointment

Name

This field is for validation purposes and should be left unchanged.