Norway Health Center - Behavioral Health Referral Form

Behavioral Health Referral Form

Information about Person Completing Referral
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Which clinic/organization are you referring from?*

Individual Information
Eligibility for Programs

All services may be covered in full or in part by Minnesota Health Care Programs (MHCP), Medical Assistance, or private health insurance. Coverage and benefits vary by plan, and members may be responsible for deductibles, co-pays, or other out-of-pocket costs.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
SSN (Eligibility Verification Purpose - Some people have the same name and DOB)
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider (MCOs)*

Medical Assisstant (MA)UCareHealth Partner (HP)Blue Cross Blue Shield (BCBS)Medica/United Health Care (UHC)AetnaSouth Country Health Alliance (NEMT ONLY)PrimeWest Health (NEMT ONLY)Other
Subscriber/PMI Number*
Insurance ID Number (If none, write NA)*
Type of Service(s) or Program(s) Needed (check all that apply)*

Adult Rehabilitative Mental Health Services (ARMHS) - Adult (Age of 18 and Over)Individual Therapy (Mental Health ONLY)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Early Intensive Developmental and Behavioral Intervention (EIDBI) (Age of 21 or younger)Comprehensive multi-disciplinary evaluation (CMDE) (Age of 21 or younger)Non-Emergency Medical Transportation (NEMT) - Ucare, SCHA, PW ONLYWaiver TransportationMNSURE Nevigation
Is the individual already enrolled with another organization? If yes, please provide adequate contact information for us to start the transfer process. If no, please go ahead and write NA.*
School Name
Parent/Guardian Name

First NameLast NameRelationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Specify service Individual is considering (Adult)

Case Management (CM)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Individual Therapy (Mental Health ONLY)Intensive Case Management (ICM)Medication Case ManagementPeer SupportsPsychosocial Rehabilitation (PSR)Psychosocial Rehabilitation - Individual (PSRI)Psychiatric Treatment (needs secondary service)Supported Employment (Mental Health ONLY)**Substance Use services
Individual Gender

MaleFemaleOther
Individual Primary Language (check all that apply)*

EnglishKarenniKarenHmongSpanishNepaliBurmeseChineseThaiLaotianOther
Care Plan Items/Goals for Norway Staff to accomplish (check all that apply)*

Citizenship / Immigration AssistanceSSI/SSDI BenefitsSNAP (Food Assistance)Utility Energy AssistanceFood Shelf / Care Package SupportCounty Financial Benefits (e.g., MFIP, GA, etc.)WIC (Women, Infants, and Children Program)Housing/Rental SupportSection 8 or Public HousingWaiver Services (e.g., CADI, BI, DD, EW)Transportation (NEMT / Waiver Ride Support)EIDBI or CMDE ServicesARMHS or Outpatient Therapy ServicesEmployment or Vocational Support ServicesMNsure Navigation SupportOther
Reason for Referral*
Current Medications*
Select all applicable challenges below for the Individual referred (check all that apply)*

Ability to avoid dangers/hazardsAngerAnxietyBehavioral challenges at home or schoolCommunity Linkage of ServicesDaily living skillsDepressionDevelopmental delay or autism spectrum disorder (ASD)GriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsLimited transportation accessMaintaining personal affairsMedication EducationNutritionalPhobia/sPRTF/Hospital DischargeSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionOther
Questions or Concerns? Feel free to reach us at (651) 300-9659. We are just a call away. Thank you for all that you do. We are grateful to serve the community alongside you.

#OneMN #StrongerTogether #Community
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Behavioral Health Referral Form

Eligibility for Programs

Questions or Concerns? Feel free to reach us at (651) 300-9659. We are just a call away. Thank you for all that you do. We are grateful to serve the community alongside you.