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 Name
Last 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.)
yes
no
Patient Name
First Name
Last Name
Patient's date of birth
-
Month
-
Day
Year
Date
Patient's primary phone number
Please enter a valid phone number.
Format: (000) 000-0000.
If applicable, parent/legal guardian #1 name:
First Name
Last 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 Name
Last 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
City
State / Province
Postal / Zip Code
Insurance
Insurance Member Number
Insurance Group Number
Anything else important to note as we follow up on this referral?
Submit
Should be Empty: