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.

 
 

 

 

 

 

 

II. Information for Individual Being Referred

Please provide information on the 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.

 
 
 

If unknown, please type "Unknown"

 
 
Phone
 
 
 

of individual being referred for services

 
 
 

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

 
 

Born in Appalachia

 
 

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

View Region Map

 
 
 
 

For children 0-21 years of age

 

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.

 

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.

 

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


For more information & FAQs click here

 

 

 

 

 

III. Emergency Contact Information

 
 

 

 

 

 

 

IV. Supporting Information

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

 
 
 

For example, problems contacting individual being referred

 
 

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.