Kentucky
SASA Tracking Tool

In-Reach Referral Form
CHFS-P&A Second Amended Settlement Agreement (SASA)

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
    • Resides in a PCH; or
    • Will be discharged from a psychiatric hospital and has previously resided in a PCH; or
    • Is at risk for entering a PCH.


To apply for assistance, complete the form below.
Referral Contact Information
Referred By
Date
05/27/2020
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
Retype the CAPTCHA code from the image
Change the CAPTCHA codeSpeak the CAPTCHA code
 
 
Application Developed By: University of Kentucky's Institute for Pharmaceutical Outcomes and Policy (IPOP)