Make a Referral : Minnesota CarePartner

COVID-19 Service Options

Please note that all of our services have transitioned to teletherapy.
We are accepting new referrals for all services. Please indicate in the referral form if there are any barriers to receiving services via teletherapy. Click to read more about our agency’s response to COVID-19 and our teletherapy platform.

Learn More

Please choose a referral type below

CTSS, ARMHS, Therapy or CSP
Roots Recovery SUD Treatment
Community Partner Referral

This page gives you two convenient options to submit a referral.

WEB BASED FORM – Use our convenient and secure Web-Based Referral Form to submit all your information directly through the web-browser. OR
PRE-FILLED PDF – If you have already completed our fillable PDF Referral Form – you can upload that by clicking on the “Pre-Filled PDF Referral Form Submission” below. You do not have to complete the web referral if you’ve filled out the PDF. You will upload the PDF to this form. Click the link if you’d like to download our PDF Referral Form There is a button at the end of the PDF form to submit the form. It will bring you back to this page to upload it once complete.

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

Date of Referral

Client First Name

Client Last Name

Date of Birth: *

Social Security Number (SSN) for insurance verification:

How did you hear about us? *

Gender: *

Female
Male
Genderqueer/Non-Binary
Prefer not to Disclose

Race/Ethnicity (Optional)

African-American
Asian/Asian-American
Native-American
Latinx
East-African
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

Single Line Text

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 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
Nutritional Services/Dietitian
Goodwill/FastX
Minneapolis Jeremiah Program
Ramsey County Community Support (for adults with children only - select additional options below)
Hennepin County Community Support (for adults with children only - select additional options below)
Other Services (indicate below)
Hennepin Learning Pod
Ramsey Learning Pod

Ramsey County CSP Services Only: (for adults with children)

Nutrition Services
In-Home Parenting Coach
Breastfeeding Support by BIPOC Staff
Trauma Informed Yoga
BIPOC Doula

Hennepin County CSP Services Only: (for adults with children)

Nutrition Services
In-Home Parenting Coach
Breastfeeding Support by BIPOC Staff
Trauma Informed Yoga
BIPOC Doula

If other services, please describe:

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:

Do you have a preference for a specific Minnesota CarePartner therapist?

Yes
No, any provider is fine

Who would you like to request?

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

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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.

Message

PDF Referral Form Submission
Use this to upload pre-filled PDF referral forms. If you have not completed a PDF form, use the web referral form on this page.
Name*
First Last
Email*
PDF Referral Form Upload*
Drop files here or
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

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 offer several convenient options for providing releases of information:

Fillable PDF versions of our release form is linked 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.
A fully electronic version of our release is available at https://mncarepartner.com/signrootsroi This link can be given to the client for completion on any computer or mobile device. We will be notified once the release is signed

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!

Name

Fillable PDF Forms

Adult Referral Form Download

Adolescent Referral Form Download

Release-of-Information-Prefilled-2 Download

This form should only be used by our official community partners.

Community Partner Referral

Standard referral form for all MH services.

Client Information
Is this referral for an adult or a minor child?*
- Adult
- Minor Child
Client Name*
First Middle Last
Client Date of Birth*
MM
DD
YYYY
Gender*
- Female
- Male
- Genderqueer/Non-Binary
- Trans
- Prefer not to disclose
Client Phone Number:*
Client Email
Minor Guardian & Contact Details
Who 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.
Name Relationship Custody Status Phone Number
Who should we contact for scheduling?*
Referent Information
Community Partner*
Contact Name
First Last
Contact Email*
Referent Phone*
Services Requested
- Diagnostic Assessment
- DC -05 Infant/Child DA
- Individual ARMHS Skills
- Individual CTSS Skills
- Individual Psychotherapy
- TeleTherapy (Zoom)
- Nutritional Services/Dietitian
- Goodwill/FastX
- Minneapolis Jeremiah Program
- Hennepin CTSS Skills Pods
- Ramsey CTSS Skills Pods
- Ramsey County Community Support (Adults w/Children Only - select options below)
- Hennepin County Community Support (Adults w/Children Only - select options below)
Ramsey County CSP Services: (Adults with Children)
- Nutrition Services
- In-Home Parenting Coach
- Breastfeeding Support by BIPOC Staff
- Trauma Informed Yoga
- BIPOC Doula
Hennepin County CSP Services: (Adults with Children)
- Nutrition Services
- In-Home Parenting Coach
- Breastfeeding Support by BIPOC Staff
- Trauma Informed Yoga
- BIPOC Doula
Supporting Documentation Upload
File
Drop files here or

COVID-19 Service Options

Please choose a referral type below

This page gives you two convenient options to submit a referral.

PDF Referral Form Submission

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

Community Partner Referral

Client Information

Minor Guardian & Contact Details

Referent Information

Contact

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