Make a Referral to Roots Recovery Make a Referral for Substance Use/Addiction Treatment at Roots Recovery Roots Recovery Referral Form Step 1 of 2 50% COVID-19 has required that we move many of our services to the Zoom teletherapy platform. Roots Recovery is currently providing hybrid services with some in-person, some via zoom. 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.Unknown 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 Referent InformationYou can skip this section if you are the client!Date of Referral* Date Format: MM slash DD slash YYYY How did you hear about us?Referent OrganizationReferent Name First Last Referent PhoneReferent Email Client InformationClient Name* First Middle Last Client Date of Birth* MM DD YYYY Client Social Security Number for insurance verificationGender*FemaleMaleGenderqueer/Non-BinaryTransPrefer not to discloseClient 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 HomeShelterSober/Group 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 Insurance/Payer InformationPrimary Insurance*We currently only accept the funding sources listed below. Please contact us at 612.564.5933 with questions. UCareMedicaid/MA/PMAPHealthPartnersBlueCrossCCDTF/BHF/Direct AccessSouth Country Health AllianceHennepinHealthUninsuredInsurance ID # or PMI #Insurance Group #Client NeedsServices Requested:*Check all that apply Adult IOP w/Sober Housing Adult IOP w/o Sober Housing Adult Step-Down IOP Rule 25/Comprehensive Assessment Is this referral from:*Check all that apply Probation/Courts Self Child Protection Mental Health Provider Sober/Recovery Residence Other SUD Treatment Provider Please describe any cultural/language needs or considerations:This may include the need for an interpreter, the desire for a provider from a specific culture, etc. Additional Information & File UploadIs a recent Rule 25 or Comprehensive Assessment available??Please attach below or fax to 612.564.5932 attention IntakeYesNoAdditional 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
