Agency Info and Waitlist Form 25-26

  • Agency Information and Waitlist Form

    2025-2026

  • Please do your best to coordinate internally and submit this form one time per agency. 

    This form has 4 sections:

    1. How we collaborate
    2. Your agency info on services
    3. Your waitlist details  (OPTIONAL- you can skip if this does not apply to you)
    4. Referral process confirmation

    To save your answers, please click the SUBMIT button at the end of the form.

  •  -

  • How We Collaborate

  • RCCMHC collaborates with mental health agencies, basic needs agencies, hospitals and other agencies who provide direct services to families. Please take a moment to review the flyer below that describes what it means to be part of the RCCMHC collaborative family.

     

    *RCCMHC was created through a joint powers agreement with Ramsey County and our six local school districts. We also partner closely with insurance providers and local foundations. Together, we work with local agencies to support families with complex needs.

  • Does your agency commit itself to collaboration across systems in Ramsey County? The minimum requirement is filling out this form one time per year.

  • Thank you for your continued collaboration! We will email you a collaborative packet for 2025-2026. This will include details about our Nonbillable Services Bank, Professional Training and Scholarship Fund, calendar of free professional trainings, and a link to our new Navigator App which you can share with your staff. 

  • Agency Information and Waitlist Details

  • Select a Path

  • Mental Health, Substance Use, and Disability

  • What services does your agency offer? Select ALL that apply
    • Intensive Outpatient Program (use the arrow to open this section) 

    • ATTENTION: read this before you select a path below.

      • START HERE. This is my first time filling out this form (use this path one time per year so you can provide general IOP agency info such as insurance, location and staff languages).
      • Skip to the waitlist section (use this to quickly jump to the waitlist section so you can provide updates throughout the year. When you select this button, it will skip over the general agency info section)
      • I need to update my IOP agency info (only use this path if you need to update your general agency info.)
    • Select a path (IOP)

    • IOP Agency Info (for youth)

    • What IOP options does your agency offer? Select ALL that apply.
    • Does your agency provide IOP services to individuals with disabilities? Select all that apply.
    • Select all locations for IOP services
    • Where/how do you deliver IOP services?
    • What insurance plans and payments do you accept for IOP services?
    • Describe the culture/ethnicities of your IOP direct service staff. Do NOT include admin staff or supervisors who do not work directly with clients.
    • Select the languages spoken by your IOP direct service staff. Do NOT include admin staff or supervisors who do not work directly with clients.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • IOP Waitlists (for youth)

    • Will you partner with RCCMHC to update your availability and waitlists?
    • IOP for mental health (only)
    • IOP for substance use (only)
    • IOP for co-occurring mental health and substance use
    • Outpatient Agency Info (use the arrow to open this section) 

    • ATTENTION: read this before you select a path below.

      • START HERE. This is my first time filling out this form (use this path one time per year so you can provide general outpatient agency info such as insurance, location and staff languages).
      • Skip to the waitlist section (use this to quickly jump to the waitlist section so you can provide waitlist updates throughout the year. When you select this button, it will skip over the general agency info section)
      • I need to update my outpatient agency info (only use this path if you need to update your general agency info.)
    • Select a path (outpatient)

    • Outpatient Agency Info

    • Select all CLINIC locations for outpatient services
    • Where/how do you deliver OUTPATIENT services?
    • What insurance plans and payments do you accept for OUTPATIENT services?
    • Does your agency provide OUTPATIENT services to individuals with disabilities? Select all that apply.
    • Describe the culture/ethnicities of your OUTPATIENT direct service staff. Do NOT include admin staff or supervisors who do not work directly with clients.
    • Select the languages spoken by your OUTPATIENT direct service staff. Do NOT include admin staff or supervisors who do not work directly with clients.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Outpatient Services and Waitlists

    • Will you partner with RCCMHC to update your availability and waitlists?

    • THERAPY

    • Therapy (ages 0 to 5)
    • Therapy (ages 6 to 10)
    • Therapy (ages 11 to 13)
    • Therapy (ages 14 to 18)
    • Therapy (adults)
    • Therapy (family)

    • OTHER OUTPATIENT INTERVENTIONS

    • ACT Team- ADULT
    • ACT Team- Youth
    • Case Management- ADULT (ARMHS)
    • Case Management- YOUTH
    • CTSS/ Skills Work
    • Early Intensive Dev & Behav (EIDBI)
    • Medication Management
    • Occupational Therapy
    • Substance Use Treatment- ADULTS
    • Substance Use Treatment- YOUTH

    • TESTING

      Our assumption is that all agencies offer Diagnostic Assessments if they offer therapy so DAs are not listed below.

    • Neuropsychological Evaluation
    • Psychiatric Evaluation
    • Psychological Evaluation (including ADHD, Autism etc.)
    • Psychoeducational Assessment
    • Substance Use Testing (youth)

    • SPECIALTIES

      Do your therapists specialize in any of these areas? These details will be added to our Search Tool

    • Abuse or Domestic Violence
    • Addiction (including gambling, social media etc)
    • Applied Behavior Analysis (ABA)
    • Art Therapy
    • Child Protection or Court Involvement
    • Disordered Eating
    • Fostercare/Kinship/Adoption
    • Grief and Loss
    • Holistic or Integrated Wellness
    • LGBTQ+
    • Music Therapy
    • Play Therapy
    • School Problems or Avoidance
    • Self Harm
    • Sensory Processing
    • Sexual Exploitation
    • Suicidal Ideation
    • Transition Age/ Independent Living
    • Trauma
  • Does your agency provide Basic Needs, Parent Support, Navigation or Other Family Services?

  • Basic Needs, Parent Support, Navigation or Other Family Services

    REMEMBER- if your agency has time sensitive or specific giveaways such as food, backpacks, a pop up health care clinic, etc. please add those details or flyers directly to our Community Bulletin Board

  • ATTENTION: read this before your select a path below.

    • START HERE. This is my first time filling out this form (use this path one time per year so you can provide general agency info such as location and staff languages).
    • Skip to the waitlist section (use this to quickly jump to the waitlist section so you can provide updates throughout the year. When you select this button, it will skip over the general agency info section)
    • I need to update my basic needs or other family service  agency info (only use this path if you need to update your general agency info.)
  • Select a path (basic needs)

  • AGENCY INFO for Basic Needs, Parent Support, Navigation or Other Family Services

  • Select all locations for BASIC NEEDS OR OTHER FAMILY SERVICES
  • Where/how do you deliver BASIC NEEDS OR OTHER FAMILY SERVICES services?
  • Describe the culture/ethnicities of your BASIC NEEDS or OTHER FAMILY SERVICES staff. Do NOT include admin staff or supervisors who do not work directly with clients.
  • Select the languages spoken by your BASIC NEEDS or OTHER FAMILY SERVICES direct staff. Do NOT include admin staff or supervisors who do not work directly with clients.

  • Basic Needs, Other Family Services and Waitlists

  • DIRECT ASSISTANCE

  • Car Repair Assistance
  • Childcare Assistance or Scholarships
  • Clothing, Diapers or Household Items
  • Food Shelf or Food Support
  • Home Repair Assistance or Grants
  • Rent or Mortgage Assistance
  • Transportation Assistance (bus cards, gas cards)
  • Utilities or Energy Assistance and micro grants

  • PROGRAMS (free or sliding scale) 

    This information will be added to our Search Tool

  • After School or Summer Youth Programs
  • Domestic Violence (non-emergency)
  • Early Childhood Programs and Support
  • Job Training or Career Coaching
  • Juvenile Diversion
  • Legal
  • Tutoring

  • PARENT SUPPORT OR NAVIGATION (free or sliding scale)

    This information will be added to our Search Tool

  • Basic Needs Navigation
  • Disability Services Navigation or Advocacy
  • Housing Navigation
  • Insurance Navigation
  • Mental Health Navigation or Advocacy
  • School Navigation or Advocacy
  • Parenting Support Group(s)
  • Parenting with CPS Involvement
  • Pregnancy and Parenting Support (adults)
  • Pregnancy and Parenting Support (teen pregnancy)
  • Substance Use Services Navigation or Advocacy

  • Referral Process

  • Select a path (referral process)

  • RCCMHC Referrals and Information Sharing

    RCCMHC manages a centralized referral portal for families with complex needs and multisystem involvement that offers a streamlined pathway to coordinated care. 

    • 97% of families sent to RCCMHC through the portal successfully complete our comprehensive youth and family screening for ongoing care.
    • Using real-time data fromlocal agencies, we match families with the best-fit provider based on specialty, availability, location, insurance, language, etc.
    • RCCMHC remains engaged after the referral—offering multisystem Care Team coordination, reminders, transportation, flex funds, drop-in parent classes and youth groups, peer coaching etc. 
    • Two-way referrals and shared care planning between RCCMHC, our system partners, and local agencies ensures more comprehensive ongoing support.

    Youth and Family Screening

    Our client families designed every detail of our Youth and Family Screening so that it addresses needs and strenghts, is trauma-informed, and culturally responsive.

    To streamline access, many local agencies accept our Youth and Family Screening instead of requiring RCCMHC to fill out their specific agency referral form(s). Although most agencies say that they appreciate the thoroughness of the screening, we realize that this option may not be possible for all agencies.

    Collaborative Authorization to Exchange and Disclose Information

    In MN, collaborative statutes allow for a simplified information sharing process with "member agencies".

    Parents and legal guardians can authorize a blanket consent of limited information sharing with any vetted agency for purposes of care coordination. This allows RCCMHC to rapidly form and mobilize multi-agency care teams without needing to go back for separate consents each time a new agency becomes involved.  RCCMHC's ROI can cover the referral and coordination conversation, allowing the Member Agency to receive: Family contact information, Basic background, Screening results, Care team notes and Service gaps or urgent needs.

    If a local agency initiates new services with the client, they will still need to collect their own signed consent and HIPAA forms.

    Parents and legal guardians always have a choice- they do not have to use this "simplified ROI process". Instead of using the blanket consent, parents and legal guardians can choose to share information only with selected agencies. 

  • Format: (000) 000-0000.
  • How can RCCMHC STAFF send referrals to your agency?

  • Submit

  • After you click on submit, you will get an automatic email that contains an EDIT LINK. 

    If you indicated that you plan to update the waitlist sections, our staff will email you a weekly reminder with the same edit link. 

    Thank you for helping to streamline access for families!

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