Download Release of Information form to fax to us at 763.780.0784 when you send us a referral: Release of Information 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 (please fax appropriate release of information to 763.780.0784 if the referred is over the age of 18). My Patient (please fax appropriate release of information to 763.780.0784). Which programs might the referred client be interested in? Clinic-Based Therapy In-Home Therapy School Based Mental Health Intensive Treatment in Foster Care Group Therapy Psychiatry & Medication Management Psychological Testing Domestic Abuse Program Bridgeview Drop-In Center CSP/Housing Support Services Does the referred client have insurance? * Yes No I don't know Referred Client's Age * Referred Client's Gender * Female Male Referred Client's Race * Alaskan Native American Indian Asian Black or African American Hispanic Multiracial White Other Unknown Reason for Referral * You should hear back from us within two business days. If you don’t, please call 763.780.3036.