Additional Service Request

Additional Services Request

Use this form to request additional providers to an already existing client or to transfer a client to a new provider. Do not use this form for new client referrals.
Referred By:
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Referrer Email*
Referrer Name*
First Last
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Relationship to client*
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Phone
Client Information
Client Name*
First Last
Age of Client
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Date of Birth
Month
Day
Year
Gender
- Male
- Female
Language Needs
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Address*
Street Address Address Line 2 City State ZIP Code
County
School or Daycare
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Insurance Information
Does the client have Kentucky Medicaid?*
- Yes
- No
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Medicaid Number
Name of Managed Care Company
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Member Identification Number
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Is the client covered by Medicare?
- Yes
- No
Transformations providers are not currently contracted to provide Medicare Services.
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Transformations providers are not currently contracted to provide Medicare services.
Does the client have commercial insurance coverage?*
- Yes
- No
Name of Primary Insurance Company*
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Member Identification Number*
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Primary Insured's Name
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Primary Insured's Birthdate
Month
Day
Year
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Does the client have a secondary commercial insurance coverage?
- Yes
- No
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Does the client have two insurance plans?
- Yes
- No
Transformations is not accepting clients covered by two insurance plans.
Name of Secondary Insurance Company
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Member Identification Number
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Secondary Insured's Birthdate
Month
Day
Year
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Secondary Insured's Name
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Guardian Information
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Name*
First Last
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Relationship to client
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Is the guardian address different than the client?
- yes
- no
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Address
Street Address Address Line 2 City State ZIP Code
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Guardian Phone
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Guardian Email Address
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Is the child in DCBS custody?
- Yes
- No
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Placement/Please select all that apply*
- Lives with parent(s)
- Lives with extended family
- Foster care
- Therapeutic Foster Care
- JCYC
- Independent Living
- Currently Hospitalized
- Home but currently attending a Partial Hospitalization Program
Services Requested
Select the Services Requested
- Targeted Case Management (TCM)
- Community Support Associate Services (CSA)
- Behavioral Health Professional (BHP)
Is this a request to transfer a case?
- Yes
- No
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Comments
*providers and hospitals please provide the diagnosis
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Please indicate the services you are interested in receiving:
- Individual and Family Counseling
- Targeted Case Management
- Community Support Services
- Telehealth
- In-person services
- In-home services
- In-office services
- Group Therapy
- I don't know yet, I would like to talk with someone first
Type of visit
- Telehealth
- In-person services
- In-home services
- In-office services
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Please indicate any services the child is currently receiving:
- Inpatient psychiatric hospitalization
- Intensive out-patient therapy
- Case Management Services
- Medication Therapy
- Therapeutic Foster Care
- Other
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Other Services:
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Is this referral for a follow-up to a mental health or chemical dependency hospitalization?
- Yes
- No
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What is the date of the discharge from the hospsital?
MM slash DD slash YYYY
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Some of our home-based providers have allergies. Please select if the following are in you home.
- Dog(s)
- Cats(s)
- Bird(s)
- Cigarette smoking
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Please tell us the days and times you are available to meet for services
Are you requesting a specific provider?
- Yes
- No
What is the name of the provider you are requesting to provide the services?
Comments
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Attach photos of the front and back of insurance cards
Drop files here or

Max. file size: 32 MB.
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Was the client accepted for services?
- Yes
- No
- Wait Listed
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Status of Denial of Services
- Client was referred to another provider or agency
- Cllient refused services
- Client did not respond to offer of services
- Client was out of service areas
- No available provider
- Agency does not accept client’s insurance
- No active insurance
- Client already had a provider in place
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Name of BHP accepting client
First Last
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Date Assigned to BHP
MM slash DD slash YYYY
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Date of initial BHP appointment
MM slash DD slash YYYY
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Name of TCM accepting client
First Last
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Date Assigned to TCM
MM slash DD slash YYYY
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Date of initial TCM appointment
MM slash DD slash YYYY
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Name of CSA accepting client
First Last
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Date Assigned to CSA
MM slash DD slash YYYY
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Date of initial CSA appointment
MM slash DD slash YYYY
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Comments
Submission ID
Phone
This field is for validation purposes and should be left unchanged.

Additional Services Request

Referred By:

Client Information

Insurance Information

Guardian Information

Services Requested