Refer a Client
Thank you for considering The Healing Project of MN. We welcome referrals from healthcare providers, schools, community organizations, and other professionals. Please complete the referral form below, and a member of our clinical team will review your submission and follow up as appropriate.
Privacy and Next Steps
This form is password-protected and encrypted to protect your privacy. We take confidentiality and data security seriously. You do not need to share any details you are not comfortable sharing. A member of our team will follow up within 1–2 business days to discuss next steps. If you have questions, please contact our intake team at 612-778-2754 or intake@thehealingprojectmn.org
Referring Provider Information
Provider
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Organization
Title
Client Information
Name
First Name
Last Name
Preferred Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of communication
Please Select
Phone Call
Text Message
Email
No preference
Do they need an interpreter?
*
Yes
No
If so, what language?
Reason for Referral | Primary Concerns
Insurance, if known
Please verify that you are human
*
I confirm that I have permission from the client (or the client's parent/guardian, when applicable) to share this information for the purpose of requesting mental health services.
Yes, ROI is attached.
No
Please upload the Release of Information.
Browse Files
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Choose a file
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After we receive your referral, our clinical team will review the information and contact the client (or referring professional, if appropriate) regarding next steps.
Please note: We will not be able to contact the referring provider if a Release of Information is not provided.
Submit
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