Make a Referral : Minnesota CarePartner

Please choose a referral type below

CTSS, ARMHS, Therapy or CSP
Roots Recovery SUD Treatment

Make a Referral for Therapy, Skills, or other MNCP Services

Use this form to make referrals for the following programs:

In Home Therapy
Adult Rehabilitative Mental Health Services (ARMHS)
Children’s Therapeutic Supports and Services (CTSS)
Supervised Visitation
Ramsey County Community Support

For your convenience, we also provide PDF versions of our referral form and release of information:

Please send a current DA (if one is available) and a Release of Information (at the bottom of this page) to our MNCP fax at 651-925-0278 or email to referrals@mncarepartner.com after your referral has been submitted.

Date of Referral

Referral Date

Client First Name

Client Last Name

Date of Birth: *

Social Security Number (SSN) for insurance verification:

Gender: *

Female
Male
Genderqueer/Non-Binary
Prefer not to Disclose

Race/Ethnicity (Optional)

African-American
Asian-American
Native-American
Latino/Hispanic
Somali
Hmong
Caucasian
Multiracial/Other
Prefer not to say

Client Phone Number: *

Best time to call?

Morning
Afternoon
Evening

Is it safe to leave a message?

Client's Email:

Preferred method of communication: *

Calls
Text
Email

Current Address:

Is this residence: *

Client’s home
Parent/Guardian home
Foster home
Shelter
Group home
Other Residence

Other residence

If the client is a minor, who has custody of the Client?

Parents
County
Other Custodian

If other custodian, please describe:

Name of Parent(s)/Legal Guardian:

Parent/Guardian Phone Number

Name of Foster Parent(s):

Foster Parent(s) Phone Number:

If Client is a minor, who should the provider schedule with?

Referent's Name: *

Referent's Phone Number: *

Referent's Email: *

Is this referral from: *

Child Protection
Mental Health
Other Referral Type

If other referral type, please describe:

Is there an ROI attached to allow MNCP to update you with care? *

Primary Insurance: *

Ucare
Medica
Medicaid/MA/PMAP
Health Partners
BlueCross
Cigna
Preferred One
Other Insurance

Other insurance:

Commercial Plans ID and Group number (separated by a comma):

Medicaid Plans ID and Group number (separated by a comma):

PMI Number:

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
School Based Mental Health
Ramsey Community Support Program (select which CSP services)
CSP Wellness Group
CSP Nutrition Services
In-Home Parenting Coach
Nutritional Services/Dietitian
Goodwill/FASTX
Minneapolis Jeremiah Program
Other Services

If other services, please describe:

If school based therapy, please select school

Ramsey Middle School
Murray Middle School
Farnsworth Middle School
Battle Creek Middle School
Four Seasons Elem/Middle
River’s Edge School

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

If other concerns, please describe:

Risk 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?

Are there any active OFP's, DANCO's, or HRO's?

If yes, please identify which and the parties involved:

Are there any other safety concerns the provider should be aware of?

Are there any cultural or language considerations?

Primary Language

Is an interpreter needed?

Client preference for worker (e.g., cultural, gender, language, etc):

Client Availability for Services: *

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings
Afternoons
Evenings

Is there a current DA? *

Additional Information

Any information you think is relevant for us to know about this referral

File Upload 1

Click or drag a file to this area to upload.

Please use this to upload releases and other documents.

File Upload 2

Click or drag a file to this area to upload.

Please use this to upload releases and other documents.

File Upload 3

Click or drag a file to this area to upload.

Please use this to upload releases and other documents.

Instructions

Please complete this form to the best of your ability.

***Please upload a release of information signed by the client to the upload link at the end of this form.

For your convenience, we also offer fillable PDF versions of our referral and release forms at the bottom of this form. The PDF forms can be uploaded to this page, emailed to roots@mncarepartner.com, or faxed to 612.564.5932.

Referral Date (Today) *

Referent Information

You can skip this section if YOU are the client and filling this out for yourself!

Referent's Name:

Referent's Phone Number:

Referent's Email:

Client Information

Is this an adult or adolescent program referral?

Adult
Adolescent

Client's Name: *

First

Middle

Last

Date of Birth: *

Social Security Number (SSN) for insurance verification:

Gender: *

Female
Male
Transgender
Non-Binary
Other Gender

If other gender, please explain

Client Contact Phone Number:

Whose number is this?

Best time to call?

Morning
Afternoon
Evening

Is it safe to leave a message?

Client's Email:

Preferred method of communication: *

Calls
Text
Email

Where does client live?

Has own residence
Family/Parent/Guardian home
Foster home
Shelter
Group home
Homeless
Other housing

If other housing, please describe:

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

Is the client currently enrolled in school?

Name of School

Please indicate attendance/truancy status:

Attending consistently
Some attendance issues, but not truant
Truant/Significant attendance issues

Juvenile Probation Status

Probation County & Officer Name:

Reason for Referral & Supporting Documents

Is this referral from: *

Probation/Court System
Self
Child Protection
Mental Health
Other referral type

If other referral, please describe:

Has the client signed, or have you attached an ROI allowing us to update you on the intake process? *

Insurance & Payment Information

Primary Insurance: (We currently only accept the plans listed below. Please contact us with questions) *

Ucare
Health Partners
BlueCross
CCDTF/County Funding
Medicaid
NO Insurance

We currently only accept the health plans indicated above. If you/your client has different insurance, please call us at 612.564.5933 to discuss options.

Insurance Plan ID:

Insurance Plan Group Number:

Insurance Type

Medicaid PMI Number:

Services & Supports Needed

Services Requested (Check all that apply): *

Adult Outpatient Treatment
Adolescent Outpatient Treatment
Adult Outpatient w/Housing Stipend
Medical/Wellness Services
Suboxone Prescribing/Consultation
Rule 25/Comprehensive Assessment
Treatment Coordination/Referral
RootsREACH Engagement Team
Recovery Management/Relapse Prevention
Other Services

If other services, please describe:

Primary Concerns (Check all that apply): *

Substance Use/Abuse
Co-Occurring Disorders
Depression‎
Anxiety‎
Post-Traumatic Stress Disorder‎
Behavioral Concerns-Home‎
Behavioral Concerns-Work‎
Behavioral Concerns-Other‎
Suicidal Ideation‎
History of Suicide Attempts‎
Self-Injurious Behavior‎
Anger Management‎
Intimate Partner Violence
History of Sexual Assault/Abuse‎
Child Abuse-Survivor‎
Emotional Regulation‎
Other Concerns

Please explain "other concerns" and which substance(s) the individual is having a problem with.

Are there cultural/language needs?

Yes, Cultural Needs
Yes, Specific Language Needs
Yes, Both
No

Please explain cultural/language needs:

Is an interpreter needed?

What language is interpreter needed for?

Is there a current Rule 25 Assessment/DA? *

File Uploads

File Upload – Please use these links to upload releases and referral forms.

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

Additional Information

You're Done?! Submit Below!

Fillable/PDF Forms

Adult Referral Form

Release of Information

Please choose a referral type below

Referral Form

Release of Information

Instructions

Referent Information

Client Information

Reason for Referral & Supporting Documents

Insurance & Payment Information

Services & Supports Needed

File Uploads

You're Done?! Submit Below!

Fillable/PDF Forms

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