NWMHC Referral Form

NWMHC Referral Form
If your client is currently experiencing a mental health crisis,
please call our crisis line at 1-800-282-5005.
Date *

Month Day Year
Referral Source Information
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Referral Relationship *
Would you like us to notify you if we cannot reach your client?
Address *

Street Address

Street Address Line 2

City State

Zip Code
Referred Client Information
Client's Legal Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Age *
Date of Birth *

Month Day Year
Date
Sex *

Male Female N/A
Interpreter needed?

Yes No
If yes, please specify language:
Billing and Insurance
Insurance Name
Insurance Policy ID #
SSN #
Used for insurance verification only.
County of Financial Responsibility
If the referral is for a child, please complete the information below:
Grade
School
Parent/Guardian Name *

First Name Last Name
Cell/Phone Number

Area Code Phone Number
Parent/Guardian is currently receiving services at NWMHC.
Date of child's last Comprehensive Evaluation/Diagnostic Assessment

Month Day Year
Where?
Is the child currently placed outside of the home?

Yes No Unknown
Foster Parent Name

First Name Last Name
Cell/Phone Number

Area Code Phone Number
Is this a new client? *

Yes No
Primary reason for referral: *

Comprehensive Evaluation/Diagnostic Assessment Psychological Testing & Evaluation* Homeless Program Psychiatry Neuropsychological Testing & Evaluation* Rule 25 Assessment **
The results of the Comprehensive Evaluation / Diagnostic Assessment will determine eligibility for subsequent services.
Primary reason for referral: *

Care Coordination with Medical Needs Case Management Comprehensive Evaluation/Diagnostic Assessment Family Assessment Family Psychotherapy Family Skills Building Homeless Program Homeless Program - Bridges Rental Assistance Individual Psychotherapy Individual Skills Building (ARMHS, CTSS, CSP, etc.) Neuropsychological Testing & Evaluation* NorthStar Summer Program Northwestern Apartments Peer Recovery Services Peer/Skills/Psychotherapy Group Pre-Petition Screening/OBRA Psychiatry Psychological Testing & Evaluation* Rule 25 Assessment ** School-Linked Mental Health Services Substance Use Treatment
Presenting concerns and potential goals *
Name of other Provider Involved/Role-Relationship/Agency
Upload Release of Information (ROI)
If client willing, NWMHC will obtain a ROI for care coordination purposes to the following entity: *
**If you are a County Social Services employee, please attach a payment agreement.
Describe Medical Needs *
Where does the client prefer to receive this service?

In-home Office
Would you like to refer this client for additional services?

Yes No
Secondary or concurrent reason(s) for referral:

Care Coordination with Medical Needs Case Management Diagnostic Assessment/Comprehensive Evaluation Family Assessment Family Psychotherapy Family Skills Building Homeless Program Homeless Program - Bridges Rental Assistance Individual Psychotherapy Individual Skills Building (ARMHS, CTSS, CSP, etc.) Neuropsychological Testing & Evaluation* NorthStar Summer Program Northwestern Apartments Peer Recovery Services Peer/Skills/Psychotherapy Group Pre-Petition Screening/OBRA Psychiatry Psychological Testing & Evaluation* Rule 25 Assessment ** School-Based Mental Health Services Substance Use Treatment
Presenting concerns and potential goals *
Please include a goal statement for each service selected above.
**If you are a County Social Services employee, please attach a payment agreement.
Describe Medical Needs
Where does the client prefer to receive this service?

In-home Office
*If referring for testing or evaluation, please complete the following information.
Referring Physician
Phone Number

Area Code Phone Number
Is this testing court ordered?

Yes No
If yes, Date results needed by court:

Month Day Year
Reason for Testing/Evaluation

What is the issue bringing you in for psychological/neuropsychological evaluation?
Check all that apply:

Chemical Dependency Issues/Dual Diagnosis Chronic Medical or Neurological Condition Developmental Delays Memory Problems Multiple Sclerosis (MS) Seizure Disorder Stroke Suspected Attention-Deficit / Hyperactivity Suspected Autism Suspected Dementia Suspected Learning Disorder Traumatic Brain Injury (TBI)
What does the client and/or the referring physician hope to learn from the testing/evaluation?
To submit medical records, please fax to 218-955-7141
Please allow 2 standard business days for the processing of referrals.
Should be Empty:

NWMHC Referral Form

If your client is currently experiencing a mental health crisis, please call our crisis line at 1-800-282-5005.

Referral Source Information

Referred Client Information

Billing and Insurance

If the referral is for a child, please complete the information below:

*If referring for testing or evaluation, please complete the following information.

Reason for Testing/Evaluation

If your client is currently experiencing a mental health crisis,
please call our crisis line at 1-800-282-5005.