Please choose an internal referral type below Refer a Roots or MH Client to Other Mental Health Services Internal Therapy/Skills Referral Form Standard referral form for all MH services. Is this referral for an adult or a minor child?* Adult Minor Child Date of Referral* MM slash DD slash YYYY Client Name* First Middle Last Client Date of Birth* Month Day Year Client Social Security Number for insurance verification Gender* Female Male Genderqueer/Non-Binary Trans Prefer not to disclose Race/Ethnicity African-American Asian-American Native American Latinx East-African West-African Caucasian/White Multiracial/Other Prefer Not to Say/Other Client Phone Number:*Parent/Guardian Information*Please enter primary guardian(s) first. Include all parties with guardianship or custody status.NameRelationshipCustody StatusPhone Number Who should we contact for scheduling?* Community Partner Contact Name (schools, PPL, FastX, CSP, etc): Community Partner Contact Phone Number: Referring Staff Name:* First Last Referring Staff Phone:*Services Requested*Check all that apply Diagnostic Assessment DC 0-5 - Infant/Child Diagnostic Individual ARMHS-Skills Individual CTSS-Skills Individual Therapy TeleTherapy (Video) Family Therapy Nutritional Services/Dietitian Goodwill/FastX Minneapolis Jeremiah Program Ramsey Community Support (for adults with children only - select additional options below) Hennepin Community Support (for adults with children only - select additional options below) Other Services (indicate below) Hennepin CTSS Skills Pods Ramsey CTSS Skills Pods If other services, please describe: Brief description of reason for referral:*Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client. Is client already in procentive?* Yes No Δ Refer a Mental Health Client to Roots Recovery Roots Recovery Internal Referral Form Referent InformationDate of Referral* MM slash DD slash YYYY Referring Staff Name: First Last Referring Staff Phone:*Referring Staff eMail:* Client InformationIs client already in procentive? Yes No Client Name* First Middle Last Client Date of Birth* Month Day Year Gender* Female Male Genderqueer/Non-Binary Trans Prefer not to disclose Client NeedsServices Requested:*Check all that apply Adult IOP w/Sober Housing Adult IOP w/o Sober Housing Adult Step-Down IOP Rule 25/Comprehensive Assessment Has client recently completed a Rule 25 or Substance Use Assessment? Yes No Unsure Additional Information about this referral:Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client. Δ Refer a Roots Recovery Client to Additional Roots Therapy Services Roots Recovery Internal Therapy Referral Form Use this form to refer Roots clients to see a Roots therapist or dietitian. Referring Staff Name:* First Last Referring Staff Email: Enter Email Confirm Email Client Name: First Last Client Primary Counselor Name:* First Last Primary Counselor Email* Roots clients must be enrolled and participating for a minimum of 3 weeks prior to starting therapy. Has this client been enrolled for 3 weeks?* Yes No Service NeedsType of Referral:* Mental Health Therapy Nutrition/Dietitian Counseling Both Services Requested:*Check all that apply Mental Health Individual Therapy Trauma-Focused Therapy Couples Therapy Family Therapy Skills-Based/DBT Therapy LOCUS - Needed for ARMHS/TCM Functional Assessment - Needed for ARMHS Updated Diagnostic Assessment Other Services Briefly explain the reason for the referral. What symptoms/issues are presenting?*Does client have any of the following services in place? Psychotherapy ARMHS/Case Management Psychiatry DBT Anger Management Domestic Abuse Programming Day Treatment/MH IOP Please indicate if you or the client have any preferences for specific therapist, telemedicine, days/times, etc:*Additional Information: Δ
