PCI/Adult Foster Care Initial Referral Form PO Box 538, 5842 Old Main Street, Suite 1 North Branch, ...

Please fill out the form completely and we will be in contact with you shortly.
Referring Agency
Client Contact
Phone number
Email Address:
example@example.com
County of Financial Responsibility
Funding Source
Legal Status/Rep.
Client Name
Date of Birth

MonthDayYear
Date
Today"s Date

MonthDayYear
Date
Current Medications (Include PRN Medications)
Psychiatrist
Address
Phone Number
Physician
Address
Phone number
Clinic
Phone number
Allergies
Special Medical Needs Medical Transport

Primary Diagnosis:
Secondary Diagnoses:
Date client is available for placement

MonthDayYear
Date
Client Address
Phone Number
Guardian
Address
Phone Number
Other Agencies Involved
Current Case Management Services Case Manager Name Phone Number
Adult Mental Health (ARMHS)
Rule 79 (Mental health)
CADI
DD
TBI
SILS
Child Protection

Race, ethnicity or tribe
Nation of origin
Length of time in the US and MN
Preferred language
Note any request for a culturally or linguistically specific provider
Type of services currently received
Current day program / Contact person
Previous placements and/or hospitalizations
Please attach the following, as applicable:

Most recent diagnostic assessment (within 6 months)Most recent CSSPOther
Notes:
*Please include client history and all other relevant information for this client.
IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPYING, DISTRIBUTING, OR ACTION TAKEN IN RELIANCE ON THE CONTENTS OF THESE DOCUMENTS IS STRICTLY PROHIBITED BY FEDERAL LAW. IF YOU HAVE RECEIVED THIS INFORMATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY AND ARRANGE FOR THE RETURN OR DESTRUCTION OF THESE DOCUMENTS. PROHIBITION OF REDISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS WHEN APPLICABLE (42 CFR PART 2) PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IF HELD BY ANOTHER PART IS NOT SUFFICIENT FOR THIS PURPOSE. FEDERAL REGULATIONS STATE THAT ANY PERSON WHO VIOLATES ANY PROVISION OF THIS LAW SHALL BE FINED NOT MORE THAN $500 IN THE CASE OF THE FIRST OFFENSE AND NOT MORE THAN $5000 IN THE CASE OF EACH SUBSEQUENT OFFENSE
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