2. Date and Time
   Date and Time
4. Client Name
5. Date of Birth:
6. Social Security Number
8. Gender
9. Does the Child(ren) have any American Indian Heritage or Tribal Affiliation?*
   -- Select One --YesNo
10. IF yes, with what Tribe(s) does the child have Heritage or Affiliation?
12. Race:
13. Hispanic
    -- Select One --Yes No
15. Disablity Code
    -- Select One --SevereNot Severe
17. Parent/ Guardian Name
19. Address
21. Mailing Address (if different)
23. City
24. State
25. Zip Code
27. Phone Number
28. Email Address:
29. Preferred way to receive paperwork/ forms:*
    -- Select One --EmailMail
31. Medicaid:
    -- Select One --YesNoNot Eligible
32. Insurance Information:
    -- Select One --State MAIMCAREPrivate InsuranceOther
33. Insurance PMI #
35. Private Insurance ***Need Copy of front and back of insurance card***
37. Policy Number#
38. Group #
39. Holder
40. Holder's DOB
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Referral Source Signature*
    By electronically signing this you acknowledge that you have spoken to the Parent/ Legal guardian and have a signed release on file to submit a referral.
46. Referral Source Address*
48. City*
49. State*
50. Zip Code
52. Additional information:
    * Attach a diagnostic assessment that has been completed in the last 180 days. * Children's Mental Health Case Management is based upon eligibility outlined in MN Statute 245.4871, Subd.6 *Screening for Case Management eligibility is competed twice a week. * INCOMPETE REFERRAL FORMS WILL BE RETURNED FOR COMPLETION TO THE REFERRING AGNECY.
54. Upload Diagnostic Assessment and/ or Additional Documentation*
55. For Additional Information if Needed
56. For Additional Information if Needed
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

* indicates a required field