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, Washington, Blue Earth, Sherburne, Stearns or Benton 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 accepts all major insurances except for Medicare.

    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. If you have any issues with submitting this form or need additional assistance please email us at