Mental Health Services Referral Form 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 servicesClient 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.UnknownClient InformationIs this referral for an adult or a minor child?*AdultMinor ChildDate of Referral* Date Format: MM slash DD slash YYYY Client Name* First Middle Last Client Date of Birth* MM DD YYYY Client Social Security Number for insurance verificationGender*FemaleMaleGenderqueer/Non-BinaryTransPrefer not to discloseRace/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*CallsTextEmailNo PreferenceDoes client currently have a physical address?*YesNoWhose Residence?Client's HomeParent/GuardianFoster HomeShelterGroup HomeClient 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)CountyFoster CareFamily MemberParent/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 OrganizationIs there an ROI attached to allow MNCP to update you with care?*YesNoReferent Email* Referent Phone*How did you hear about us?*Insurance/Payer InformationPrimary Insurance*UCareMedicaMedicaid/MA/PMAPHealthPartnersBlueCrossCignaPreferred OneUninsuredInsurance 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 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:Ramsey County CSP Services: (for adults with children) Nutrition Services In-Home Parenting Coach Breastfeeding Support by BIPOC Staff Trauma-Informed Yoga BIPOC Doula Hennepin County CSP Services: (for adults with children) Nutrition Services 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?*YesNoIf 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.YesNoClient 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?*YesNoPrimary Language:*Client Availability for Services:* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Mornings Afternoons Evenings Is an interpreter needed?*YesNoSafety ConcernsRisk of Harm to Self:*LowMediumHighCrisisRisk of Harm to Others:*LowMediumHighCrisisIf Child Protection Involvement, please provide harm statement and collateral info:Is there violence in the home?*YesNoAre there any active OFP's, DANCO's, or HRO's?*YesNoIf 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
