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 or your client declines services?
Please attach Release of Information; NWMHC will only contact you with a ROI on file. *

Browse Files

Cancel of
Address *

Street Address

Street Address Line 2

City State

Zip Code
Referred Client Information
Legal Name *

First Name Last Name
Preferred Name

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Date
Age *
Sex *

Male Female N/A
Gender *

Cisgender (your gender is the same as birth sex) Gender Variant Intersex Transgender Female Transgender Male 2-spirit Non-binary Other Prefer Not to Answer Unknown
Pronouns *

He/Him/His She/Her/Hers They/Them/Their Prefer Not to Answer Unknown
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
For many of our services, new clients must complete a Comprehensive Evaluation / Diagnostic Assessment to determine eligibility for services. The clinical provider will make recommendations for services based upon diagnosis, stage of change, and clinical appropriateness.

If you have a specific service(s) you wish to see for your client, please include your recommendation in the Presenting concerns and potential goals text box below. This will give our clinical providers an indication of why you are making a referral and the services you believe would be most beneficial to the individual.
Primary reason for referral: *

Comprehensive Evaluation/Diagnostic Assessment Psychological Testing & Evaluation* Homeless Program Psychiatry Rule 25 Assessment ** Northwestern Apartments
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.) 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
Current or past diagnoses:
Attach any supporting Diagnostic Assessment or Comprehensive Evaluation:

Browse Files

Cancel of
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.) 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
Current or past diagnoses:
Attach any supporting Diagnostic Assessment or Comprehensive Evaluation:

Browse Files

Cancel of
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 you'd like to make an appointment for psychological testing or evaluation, please fill out this form.

Psychological testing is available for children ages seven and up, teens, and adults.
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 evaluation?
Check all that apply:

Chemical Dependency Issues/Dual Diagnosis Developmental Delays Memory Problems Seizure Disorder Suspected Attention-Deficit / Hyperactivity Suspected Autism Suspected Dementia Suspected Learning Disorder Traumatic Brain Injury (TBI) Suspected Intellectual Delay
What does the client and/or the referring physician hope to learn from the testing/evaluation?
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:

Reason for Testing/Evaluation

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