Recovering Hope Referral Form
Mental Health Services
Client Information
Full Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
SSN
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Services
Check all that apply
Services
Diagnostic assessment
Individual therapy
Animal assisted therapy (AAT)
Eye movement desensitization reprocessing (EMDR)
Family therapy
Couples therapy
Psychological testing
Telehealth sessions
Insurance & Funding
Financial Sources ( select all that apply )
Commerical Insurance
Minnesota Medicaid:Including: MA and Pmaps: BCBS Pmap, HealthPartners Pmap, UCare pmap, Medica Pmap, PrimeWest Pmap, Itasca Medical Care Pmap
Medicare
Self-Pay
Uninsured
If you're currently uninsured, we are unable to begin mental health services at this time. However, we're always here to help.Please call our receptionist at 320-364-1300, and we’ll connect you with our financial team. They can help guide you—whether that's accessing services with us or finding programs you may qualify for elsewhere.
If you currently have Medicare only, please call Recovering Hope at 320-364-1300. Our team can let you know if you may qualify for services with us or connect you with resources and programs that do accept Medicare.
Insurance Provider Name
Member/PMI ID Number
Group Number
Are you referring a client to Mental Health services?
Yes
No
Referring Agency
Referring Agency Phone Number
Referring Agency Email
Relationship to Client
Scheduling/Planning
When are you hoping to begin mental health services?
-
Month
-
Day
Year
Date
Additional Notes or Relevant Information
Submit
Should be Empty: