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.