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Referral

Referral

*For the ARMHS referral form, please click here

Phone

Referent's Information

Referent First Name *

Referent Last Name *

Referent Phone # *

Referent Email Address

Referent Title/Role

Referent Organization Affiliation (if any)

Referred Client's Information

Referred Client's First Name *

Referred Client's Last Name *

Referred Client's Phone Number *

My Relationship to the person being referred is: *

Self

My Child

My Family Member

My Patient

Which programs might the referred client be interested in? (Pick Top Three)

Clinic-Based Therapy

In-Home Individual Therapy- Youth (Ages 2-17)

In-Home Therapy Adult - ARMHS

Children's Therapeutic Services & Supports- CTSS (Medical Diagnosis Required)

School Based Mental Health (SLMH)

Intensive Treatment in Foster Care (ITFC)

Group Therapy

Psychiatry & Medication Management

Psychological Testing

Domestic Abuse Program- Aggressor/ Survivor

Bridgeview Drop-In Center

CSP/Housing Support Services

Play Therapy

Housing Stabilization

Does the referred client have insurance? *

Yes

No

I don't know

Insurance Type (If none or unknown, type N/A) *

Referred Client's Age *

Referred Client's Gender

Referred Client's Race

Reason for Referral *

You should hear back from us within 24 hours or less. If you don’t, please call 763.780.3036.

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STAFF PORTAL
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WEBSITE PRIVACY POLICY

Patient Portal Instructions

Many sliding fee arrangements and discounts are available to those who qualify. Are you uninsured? Speak with our MNSure Navigators about health insurance coverage options you may be eligible for. No one is turned away for their inability to pay.

Lee Carlson Center | 763.780.3036

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