Peer Recovery Support Referral Form

Peer Recovery Support Referral Form
THIS FORM MUST BE FILLED OUT COMPLETELY, PLEASE PUT N/A IF NOT APPLICABLE If any information is missing, this could delay services

Referrals must be faxed to 612-886-3940 or emailed to referrals@minnesotarecovery.org
Referral Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth
Gender
Date of Comprehensive Assessment
If applicable please fax or email comprehensive Assessments to

Fax#: (612) 886-3940 or Email: referrals@minnesotarecovery.org
Referral Contact
Referral Phone Number
Please enter a valid phone number.
If participant has a PMAP/Insurance, please enter ALL information below
MCO Provider
Group #
Policy/Subscriber #
Medicaid ID/PMI#
If participant has "straight MA" - only Medical Assistance, please enter ALL information below
Medicaid ID/PMI #
Referral must include a comprehensive assessment that indicates at least a risk rating of 1 in Dimension 4, 5, or 6 and must include a recommendation for Peer Services.
Primary SUD diagnosis (enter code i.e. f11. 20, f12.20, etc.)
Service start date (enter the date the referral is sent - mm/dd/yyyy)
Check services provided (can only be 1:1 service but can attend a group with a participant)

EducationAttending recovery and other support groupsAccompany the client to appointments that support recoveryAssistance in accessing resourcesRecovery support to assist a person in the transition from treatmentAdvocacyMentoringOther
Please indicate Peer Recovery Specialist preference (if any): i.e. Male, Female, African American, Native etc. Due to availability, we cannot guarantee to accommodate all preferences.
Should be Empty:

Peer Recovery Support Referral Form

If applicable please fax or email comprehensive Assessments to

If participant has a PMAP/Insurance, please enter ALL information below

If participant has "straight MA" - only Medical Assistance, please enter ALL information below

Referral must include a comprehensive assessment that indicates at least a risk rating of 1 in Dimension 4, 5, or 6 and must include a recommendation for Peer Services.