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

To be eligible for ARMHS and psychotherapy, the patient is recommended to have Medical Assistance (MA) or MN Care. For HSS, only MA recipients are eligible. If the patient does not have MA or MN Care, ARMHS and therapy services may be covered by private insurance or state health programs, though coverage specifics can vary and out-of-pocket costs may apply.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
SSN (Eligibility Verification - 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*

UCareMAHealth PartnerBlue Cross Blue Shield (BCBS)Medica/UHCAetnaOther
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 (18 and Over)Individual Therapy (Mental Health ONLY)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Housing Stabilization - HSS
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)*

CitizenshipSSI/SSDI BenefitsSNAP BenefitsUtility Energy AssistanceFood/Care PackageFinancial County BenefitsWICHousing/Rental SupportOther
Reason for Referral*
Current Medications*
Select all applicable challenges below for the Individual referred (check all that apply)*

Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining 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 thankful to serve the community together with 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 thankful to serve the community together with you.