Behavioral Health Referral Form
If you have questions about the intake process or need assistance, please get in touch with our Intake Team at intake@thehealingprojectmn.org. Thank you!
Information about Provider Submitting Referral
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of Employer
Client Information
Name
First Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for referral
Healing Minds/ Resource Navigation
Children's Therapy
Teen Talk - Therapy Services
Individual Therapy
Family Therapy
Other
Is the individual aware of this referral?
Yes
No
Please upload a release of information if you have obtained one from the client you are referring to The Healing Project of MN. If you do not have a ROI, we will ask the client if they want to sign one for your agency and/or school when we make contact. If the client signs a ROI, we will keep you updated on the referral process.
Browse Files
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Does the client need an interpreter?
Please Select
Yes
No
Please indicate what language, if the client needs an interpreter.
Parent/Guardian Name (this is only required if the client is under the age of 15, per Minnesota Statute Sec. 144.3431 OR if teens ages 16+ want their parents/ guardians involved in their mental health care).
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Select all challenges below for the client you are referring.
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Please add a SHORT description of the current challenge(s).
Submit
Should be Empty: