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  • NWMHC Referral Form

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

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  • Referral Source Information

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  • Referred Client Information

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  • Billing and Insurance

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

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  • 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. 

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  • *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. 

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  • Reason for Testing/Evaluation

    What is the issue bringing you in for psychological evaluation?

  • To submit medical records, please fax to 218-955-7141 

  • Please allow 2 standard business days for the processing of referrals.

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