Kentucky
Data Tracking Tool

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In-Reach Referral Form
CHFS-P&A Third Amended Settlement Agreement (TASA)

Across Kentucky, persons having a serious mental illness (SMI) who currently live in a Personal Care Home (PCH) or are at risk of entry into a PCH, may apply for assistance and services in an integrated setting. Every Community Mental Health Center (CMHC) can provide transition services to residents of personal care home who meet the eligibility criteria shown below and want to move into their community. Individuals are eligible regardless of guardian status; they may be their own guardian, or have a private or state guardian.

To be eligible, a person must meet the following criteria:
  • Is at least 18 years old; and
  • Has a serious mental illness; and
  • Receives or may be eligible for state Community Integration Supplementation (CIS); and
  • Meets one of the following criteria


To apply for assistance, complete the form below.
Referral Contact Information
Referred By
Date
12/16/2024
Phone
Email
Referral Type
In-Reach Referral Form
Individual's Name (First/Last)
Phone Number
Date of Birth
Name of
Client Counties of Choice
Guardian
Type
Name
Email
Phone
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Application Developed By: University of Kentucky's Institute for Pharmaceutical Outcomes and Policy (IPOP)