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Referral

REFER A CLIENT

Together, We Can Make a Difference

Thank you for considering Open Mind Center. Your referrals help connect adults facing mental health challenges with
the support and resources they need to live more independently and fulfilling lives.

Refer Someone Today

Community-Based Services Intake Referral – Adults (ARMHS)

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This field is for validation purposes and should be left unchanged.

Client Information

Client Name(Required)

First

Age(Required)

Please enter a number from 1 to 150.

DOB(Required)

MM slash DD slash YYYY

Gender(Required)

Soc. Sec. #(Required)

Race(s)(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Work/Cell Phone(Required)

Number of adults living in the home(Required)

Number of children living in the home(Required)

Legal Guardian Information (if adult has a designated guardian)

Legal Guardian’s name(Required)

First

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Referral Information

Referral Source(Required)

Agency/Division(Required)

Phone(Required)

Fax(Required)

Current Soc. Serv./Psych. Involvement(Required)

Yes

If yes, please describe(Required)

Current Diagnoses (if any)(Required)

2(Required)

Current Concerns(Required)

Medications(Required)

Reason for Referral(Required)

Untitled(Required)

Yes

If yes, please describe(Required)

Therapist Requested(Required)

Financially Responsible Party (please check all that apply)

Medical Assistance

3rd Party Insurance

MA #(Required)

Carrier(Required)

PMAP(Required)

Policy Holder(Required)

ID #(Required)

Policy #(Required)

Group #(Required)

Prov. Serv. #(Required)

Country

Prov. Serv. #

Please fax or email completed referral form, along with ALL of the following (that apply) to admin@openmindcentermn.org:

Current Diag. Assess

Referring Agency Release

Referral Source Release

County Contract/Ppwk

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Contact Information

(111)-222-3444

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