Referral Form

1 Step 1
Complete Online and submit.
Call 270-444-3650 if have questions.
Has Guardian Participated in IMPACT Referral?
Parental Signature
(Sign Here)
Clear Signature
Does Child Have an IEP or Receive Special Education Services?
Has Child Had Residential/Hospitalization Placement
Type of Placement?
Is Child in Counseling?
Does Child have a Mental Health Diagnosis?
Is Child on Medication for Emotional, Behavioral, or a Psychiatric Disorder/Diagnosis?pick one!
Has Child ever been the victim of/perpetrator of sexual abuse/physical abuse or neglect?
Does Child have a history of using/abusing alcohol or drugs?
Is Child currently involved with:Check all that apply
Reasons for Referral (Check all that Apply for problematic behaviors over last year):

Referral will not be processed until the CASII or ECSII Score and Level are received.

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