If the referral is for a child, please complete the information below:
Please check the appropriate location of service where specified (Home/Office).
Services with an * after them require additional information so complete the box that applies below)
* If referring for testing or IPS, please complete the following information.
If referring for Testing, complete the following:
(what is the issue bringing you in for psychological/neuropsychological evaluation?):
IPS* Internal NWMHC Referrals Only*
If referred for IPS, Have the client answer the following questions:
ROI for ODC is on file
(Release of information is required for Occupational Development Center (ODC) to be on file prior to referral being submitted)
To submit medical records, please fax to 218-281-6261
For Office Use Only: