SUD Self Referral Form

Recovering Hope Referral Form

Substance Use Services
Requested Services

Check all that apply
Services

Women’s Residential Treatment (ASAM 3.5 – High Intensity)Women’s Residential Treatment (ASAM 3.5 – Medium Intensity)Residential Transportation for IntakeIntensive Outpatient Treatment (ASAM 2.1) + Board and LodgingIntensive Outpatient Treatment Only (ASAM 2.1)Outpatient Treatment (ASAM 1.0)Comprehensive SUD Assessment
Have you had a Comprehensive Assessment that recommends the level of care you are requesting?

YesNoI'm not sure
Have you completed a comprehensive assessment in the past 6 months?

YesNo
If yes, who completed the assessment (name of provider or agency)?
Have you ever had a comprehensive assessment with us before?

YesNo
If yes, are you requesting an update to your previous assessment?

Yes, I need an updateNo, I need a new one
If you already have a comprehensive assessment, you’ll be able to upload it at the end of this form.

If you’re not able to obtain a copy — no worries. Our admissions team will work with you to either get it from the provider or we will complete one at the time of intake.

Tip: Uploading your assessment now can help speed up the intake process, since you may be able to skip the screening and go straight into intake.
Not sure what level of care you need? No problem.
Recovering Hope offers walk-in Comprehensive Assessments between 8:00 AM and 1:00 PM, Monday through Friday.

Please call us at 320-364-1300 and let us know you're looking for Direct Access into treatment. Depending on bed and group availability, we may be able to get you started the same day.

We’re here to help—you’re not alone.
Need a Comprehensive Assessment Quickly?
Recovering Hope offers walk-in assessments Monday through Friday from 8:00 a.m. to 1:00 p.m. Whether the assessment is required by a court, employer, probation officer, or another agency—we’re here to help.

Our team will support you through the process and help identify the next steps based on your results. You always have a choice in what comes next, and we’re here to guide you—whether that’s starting services with us or connecting you to a program that’s the right fit.
How did you hear about Recovering Hope?
Your Information
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance and Funding
Do you have healthcare coverage or secure funding?

YesNo
Have you already applied for insurance?

YesNo
Do you need help applying for health Insurance?

YesNo
Please indicate the County of Financial Responsibility or the county you last applied for healthcare coverage in:
Primary Funding Sources ( select all that apply )

Minnesota Medicaid (MA): Includes PMAP plans like BCBS, UCare, Medica, Health Partners, and Hennepin Health.MNcare: A state program that provides affordable health coverage to individuals and families with low income who don't qualify for Medicade.MedicareCommercial InsuranceSelf-PayBehavioral Health Fund ( OO span )Other
Insurance Provider Name
Member/PMI ID Number
Group Number
Bringing a Child to Residential
Are you planning to bring your child with you, or reunifying while in treatment?

YesNo
Name and Date of Birth of Child:
Is there CPS/ICWA involvement?

YesNo
If Yes, what is the CPS/ICWA workers name?
Once we are aware of your intent to reunify or bring your child with you, our Admissions team will conduct a brief screening to identify any potential barriers.

If reunification occurs during treatment, your counselor will conduct a screening and place you in a “Mom Room” once barriers are resolved—or place you on a waitlist if one is not immediately available.

We want to ensure a safe and supportive environment for both you and your child.
Legal System Involvement
Select all that apply:

Being released from jailOn a furloughUnder full civil commitmentUnder partial civil commitmentUnder legal guardianshipOther
Scheduling/Planning
Expected Date of Engagment in Services

MonthDayYear
Date
Additional Notes or Relevant Information
Clinical Documentation Upload
If applicable, please upload the most recent comprehensive assessment you have completed.
File Upload

Cancelof
Aknowledgment
I confirm that the information provided in this form is accurate to the best of my knowledge. I understand that this form is for referral and admission purposes only and does not replace the formal intake and consent process.

I acknowledge that, as the client, I will complete an informed consent and review the client handbook during intake.
Signature

Clear
Should be Empty:

Recovering Hope Referral Form

Requested Services

Your Information

Insurance and Funding

Bringing a Child to Residential

Legal System Involvement

Scheduling/Planning

Clinical Documentation Upload

Aknowledgment