KPFC Peer Support Services Referral

KPFC Peer Support Services Referral

This form requests information for the following areas:

I. Your Information

II. Information for Individual Being Referred

III. Emergency Contact Information

IV. Supporting Information

Once your referral is received, KPFC will process the information and contact you for next steps.

If you would like additional information on KPFC Peer Support, please visit our website

Please note: In regions where we have established formal peer support partnerships, your referral may be followed up or fulfilled by a local peer support provider affiliated with our organization.

I. Your Information

Please provide your information.

Select the option that best describes you*

Select

Your County*

This is the Referral Source Location

If you serve multiple counties, please select the county relevant to this referral

Select

Your First Name*

Your Last Name

Your Job Title*

Your Agency Type*

Select

Your Agency Name*

Your Email*

Your Phone*

Phone

II. Information for Individual Being Referred

Please provide information on the individual being referred.

Family role of individual being referred*

Note: this information will be used to identify type of peer support needed: Family or Youth.

If services are needed for more than one individual, please fill out a separate referral for each person.

Select

First Name*

Last Name*

Address*

If unknown, please type "Unknown"

Phone

Is this person able to receive support virtually or by phone?*

Select

Age*

of individual being referred for services

Select

Gender*

Select

Sexual Identity*

Select

Ethnicity*

Is the individual being referred of Hispanic, Latino, or Spanish origin?

Select

Race*

Select

Native Appalachian*

Born in Appalachia

Select

County of Residence*

Select

DCBS Region*

Please right click the below link to view the Regional Map in another tab

View Region Map

Select

Has the individual being referred to Peer Support, also been referred to a BHP or CMHC?*

Select

Is the Department of Juvenile Justice (DJJ) involved with this individual or with any of the youth in their care?*

Select

Which category best describes this individual's involvement with the Administrative Office of the Courts (AOC)?*

Select

Is the Department for Community Based Services (DCBS) involved?*

For children 0-21 years of age

Select

Please indicate the type of DCBS response measure being taken*

Traditional Response is the way DCBS has been “doing business” for a long time: report, investigation, abuse or neglect is substantiated; family receives child welfare services that often include out of home care.

Alternative Response is a new approach for managing certain low to medium risk reports of child abuse and neglect. Alternative Response allows workers to postpone an investigation and tailor specific services to the families for six weeks to mitigate the crisis that brought the report to DCBS.

Community Response does not meet eligibility as a referral, so families are connected to community agencies that will provide services and supports to prevent the family from returning as a DCBS referral in the future.

Select

Please select the child's status*

For any child 0-21 years of age, status refers to their current placement

Examples of Out-of-Home: Residential or Inpatient Treatment, Non-Traditional Placement (NTP), Foster Care, Psychiatric Hospital, Juvenile Detention, DJJ placement, etc.

Select

Non-Traditional Placement: Is this referral for a Youth in Non-Traditional Placement?*

To be considered Non-Traditional Placement, the youth must be in short-term, out-of-home care, with no identified placement options.

For more information & FAQs click here

Select

III. Emergency Contact Information

Can you provide emergency contact information for the individual being referred?*

Select

Emergency Contact Name*

Emergency Contact Phone*

Phone

Relationship to individual being referred*

Referral Source Emergency Phone*

Please provide a contact phone number to use outside of normal business hours

Phone

IV. Supporting Information

Note: Please upload Release of Information form for client file.

Please explain your reason(s) for submitting this referral*

Please provide any additional causes for concern

For example, problems contacting individual being referred

Please select all documents you are able to provide*

Includes current plans available for the individual being referred, as well as a Release of Information (ROI) form. You may upload all files using the File Upload option.

Select

File Upload*

Please upload all documents you listed in the previous question or any other supporting documentation you have available. You may upload up to 10 files.

Drag and drop files here or

Please provide any additional information

Send me a copy of my responses

Privacy Notice|Report Abuse