Make a Referral to Roots Recovery Make a Referral for Substance Use/Addiction Treatment at Roots Recovery Please 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 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 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!EmailSubmit Roots Referral Form Fillable PDF Forms Release of InformationDownload Adult Referral FormDownload Adolescent Referral FormDownload
