Make a Referral to Roots Recovery Make a Referral for Substance Use/Addiction Treatment at Roots RecoveryPlease enable JavaScript in your browser to complete this form.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 InformationYou 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 InformationIs this an adult or adolescent program referral?AdultAdolescentClient's Name: *FirstMiddleLastDate of Birth: *Social Security Number (SSN) for insurance verification:Gender: *FemaleMaleTransgenderNon-BinaryOther GenderIf other gender, please explainClient Contact Phone Number:Whose number is this?ClientParent/GuardianCase Manager/WorkerShelter/Group HomeOtherBest time to call?MorningAfternoonEveningIs it safe to leave a message?YesNoClient's Email:Preferred method of communication: *CallsTextEmailWhere does client live?Has own residenceFamily/Parent/Guardian homeFoster homeShelterGroup homeHomelessOther housingIf other housing, please describe:Client's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs the client currently enrolled in school?NoYesName of SchoolPlease indicate attendance/truancy status:Attending consistentlySome attendance issues, but not truantTruant/Significant attendance issuesJuvenile Probation StatusUnknownNot on ProbationOn ProbationProbation County & Officer Name:Reason for Referral & Supporting DocumentsIs this referral from: *Probation/Court SystemSelfChild ProtectionMental HealthOther referral typeIf other referral, please describe:Has the client signed, or have you attached an ROI allowing us to update you on the intake process? *YesNoInsurance & Payment InformationPrimary Insurance: (We currently only accept the plans listed below. Please contact us with questions) *UcareHealth PartnersBlueCrossCCDTF/County FundingMedicaidNO InsuranceWe 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 TypeCommercialPrepaid Medical Assistance Plan (PMAP)Medicaid PMI Number:Services & Supports NeededServices Requested (Check all that apply): *Adult Outpatient TreatmentAdolescent Outpatient TreatmentAdult Outpatient w/Housing StipendMedical/Wellness ServicesSuboxone Prescribing/ConsultationRule 25/Comprehensive AssessmentTreatment Coordination/ReferralRootsREACH Engagement TeamRecovery Management/Relapse PreventionOther ServicesIf other services, please describe:Primary Concerns (Check all that apply): *Substance Use/AbuseCo-Occurring DisordersDepressionAnxietyPost-Traumatic Stress DisorderBehavioral Concerns-HomeBehavioral Concerns-WorkBehavioral Concerns-OtherSuicidal IdeationHistory of Suicide AttemptsSelf-Injurious BehaviorAnger ManagementIntimate Partner ViolenceHistory of Sexual Assault/AbuseChild Abuse-SurvivorEmotional RegulationOther ConcernsPlease explain "other concerns" and which substance(s) the individual is having a problem with.Are there cultural/language needs?Yes, Cultural NeedsYes, Specific Language NeedsYes, BothNoPlease explain cultural/language needs:Is an interpreter needed?YesNoWhat language is interpreter needed for?Is there a current Rule 25 Assessment/DA? *YesNoFile UploadsFile 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 InformationYou're Done?! Submit Below!CommentSubmit Roots Referral Form Fillable/PDF FormsAdult Referral FormRelease of Information
