Branch Mental Health Referral Form

Branch Mental Health Referral Form
If you prefer, referrals may also be placed via fax (612-500-4553, attention intake) or phone (651-333-3677). Please complete as much of the following information as possible. Thank you for your referral!
Name of individual requesting referral:

First NameLast Name
Relationship to patient:
Reason for referral:
What is the best way to reach you if we need to follow up?
Would you like to be updated on the status of your referral? (If yes, please make sure your contact information is completed above.)
Patient Name

First NameLast Name
Patient's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's primary phone number
Please enter a valid phone number.Format: (000) 000-0000.
If applicable, parent/legal guardian #1 name:

First NameLast Name
Parent/legal guardian #1 phone number:
Please enter a valid phone number.Format: (000) 000-0000.
If applicable, parent/legal guardian #2 name:

First NameLast Name
Parent/legal guardian #2 phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Patient's primary address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance
Insurance Member Number
Insurance Group Number
Anything else important to note as we follow up on this referral?
Should be Empty:

If you prefer, referrals may also be placed via fax (612-500-4553, attention intake) or phone (651-333-3677). Please complete as much of the following information as possible. Thank you for your referral!