Mental Health Referral/Intake Form


    Mental Health Health Referral Intake Form



    Client Information

     


     
    Can we text this number? YesNo
    Can we use email? YesNo
     
     
     
     
     
     
     
     
    Referring Information

     
     
    Diagnostic Information

     
    Staffing Preferences

     

    Eligible clients must be at least 18 years of age, have a qualifying mental health diagnosis, and reside in Anoka, Dakota, Hennepin, Ramsey, Scott, Carver, or Washington counties. ARMHS recipients must have medical assistance or coverage through a prepaid medical assistance program (PMAP, for example, Blue Plus, Metropolitan Health Plan, etc.) In-home therapy recipients must have medical assistance, UCare/UCare SNBC, or Medica SNBC. Unfortunately, we do not accept Health Partners PMAP.

    As soon as we receive a referral, Alliance Health Care staff will begin processing and verifying insurance coverage. If a client has “inactive” insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.