Standard referral form for all MH services. COVID-19 has required that we move all of our services to the Zoom teletherapy platform. All that is required to take advantage of this is a smart device with internet access and a camera. Please indicate the client's ability to utilize teletherapy services below.* Client has the technology, internet access and support to access teletherapy services Client has access to internet, but may need assistance with getting a device to access teletherapy services. Client does not have consistent access to internet or technology to access teletherapy services. Unknown Client InformationIs 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:*Best Time to Call?* Morning Afternoon Evening No Preference Is it safe to leave a message?*YesNoClient Email Preferred Method of Communication* Calls Text Email No Preference Does client currently have a physical address?*YesNoWhose Residence? Client's Home Parent/Guardian Foster Home Shelter Group Home Client Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Minor Guardian & Contact DetailsWho has custody of the minor child?* Parent(s) County Foster Care Family Member 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?* Referent InformationReferent Name* First Last Referent Organization Is there an ROI attached to allow MNCP to update you with care?* Yes No Referent Email* Referent Phone*What is your relationship to the client? (current therapist, case manager, family member, self referral, etc)* Insurance/Payer InformationPrimary Insurance* UCare Medica Medicaid/MA/PMAP HealthPartners BlueCross Cigna Preferred One Uninsured Insurance ID # or PMI # Insurance Group # Services Needs & Primary ConcernsServices 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 Goodwill/FastX Minneapolis Jeremiah Program Ramsey Community Support (for adults with children only - select additional options below) Other Services (indicate below) If other services, please describe: Ramsey County CSP Services: (for adults with children) Nutrition Services (at capacity) In-Home Parenting Coach Breastfeeding Support by BIPOC Staff Trauma-Informed Yoga BIPOC Doula Primary Concerns:*Check all that apply Depression Anxiety Post-Traumatic Stress Disorder Psychosis Autism Spectrum Disorder Aggression Behavioral Concerns-Home Behavioral Concerns-Work Behavioral Concerns-Other Suicidal Ideation Homicidal Ideation History of Suicide Attempts Self-Injurious Behavior Recent Life Transition Parenting Challenges Anger Management Intimate Partner Violence-Survivor Intimate Partner Violence-Child Witness Intimate Partner Violence-Perpetrator History of Sexual Assault/Abuse Child Abuse-Survivor Child Abuse-Perpetrator Emotional Regulation Other Concerns Is there a current DA?* Yes No If other concerns, please describe: Do you have a preference for a specific therapist, or for a therapist with a specific cultural background?*Examples include specific gender, Spanish-speaking, African-American or Hmong, etc. Yes No Client preference for worker (e.g., cultural, gender, language, etc):*Please indicate a specific therapist's name or you cultural/language preferences here. If a specific provider or culturally specific provider isn't available, is the client willing to see the soonest available provider?* Yes No Primary Language:* Client Availability for Services:* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mornings Afternoons Evenings Is an interpreter needed?* Yes No Safety ConcernsRisk of Harm to Self:* Low Medium High Crisis Risk of Harm to Others:* Low Medium High Crisis If Child Protection Involvement, please provide harm statement and collateral info:Is there violence in the home?* Yes No Are there any active OFP's, DANCO's, or HRO's?* Yes No If yes, please identify which and the parties involved:* Please list any other safety concerns the provider should be aware of:*Additional Information & File UploadAdditional 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. File UploadUpload any DA, release of information, court/CPS records, or other pertinent information Drop files here or Select files Max. file size: 1 GB.
