Roots Wellness
Center
(612) 289-5656
info@rwc-mn.com
393 N Dunlap St, Ste #300, St Paul
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Mental Health Therapy
ARMHS Services
CTSS Services
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Hennepin County Be@School
Hennepin In-Home Recovery Pilot
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Make a Referral
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.
Name
Relationship
Custody Status
Phone 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
Refer a Mental Health Client to Roots Recovery
Roots Recovery Internal Referral Form
Referent Information
Date of Referral
*
MM slash DD slash YYYY
Referring Staff Name:
First
Last
Referring Staff Phone:
*
Referring Staff eMail:
*
Client Information
Is 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 Needs
Services 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.
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 Needs
Type 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:
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Minnesota CarePartner/Roots Recovery is now
Roots Wellness Center
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