First NameLast NameDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security NumberGenderMaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Client PhoneEmail Enter Email Confirm Email Date of ReferralMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason for ReferralDescribe Service NeedsReferral SourceReferral SourceCommunity ProviderCountyFamily/FriendLaw EnforcementMedical FacilitySchool/CollegeSelfCommunity ProvidersCommunity ProviderAdult/Teen ChallengeAssociates in Psychiatry and PsychologyAttorneyBlue StemChemical Dependency FacilityCourtEAPEmployerEmpowerFamily Service RochesterGroup HomeIRTSNAMIOther CourtOther ProfessionalPhysicianPrairie CarePsychiatristPsychologistRecovery is HappeningVocational Rehab/Employment ServicesCountyCountyBlue Earth CountyDodge CountyFillmore CountyGoodhue CountyHouston CountyMower CountyOlmsted CountyOlmsted County Social ServicesOther County AgencyParole OfficerRice CountySocial ServicesSocial WorkerSteele CountyWabasha CountyWinona CountyFamily/FriendFamily/FriendFamily/RelativeFriendLaw EnforcementLaw EnforcementBlue Earth County Sheriffs DepartmentDodge County Sheriffs DepartmentFillmore County Sheriffs DepartmentGoodhue County Sheriffs DepartmentHouston County Sheriffs DepartmentLaw Enforcement AgencyMN Department of CorrectionsMower County Sheriffs DepartmentOlmsted County Sheriffs DepartmentRice County Sheriffs DepartmentRochester Police DepartmentSteele County Sheriffs DepartmentWabasha County Sheriffs DepartmentWaseca County Sheriffs DepartmentWinona County Sheriffs DepartmentMedical FacilityMedical FacilityAustin Medical CenterCommunity Behavioral HospitalMayo ClinicMayo Health SystemMental Health AgencyNursing HomeOlmsted Medical CenterOther Hospital/Medical CenterRapid Access ClinicSt. Mary's Hospital/Generose/MayoVeteran's HospitalVeteran's ServicesSchool/CollegeSchool/CollegeALCALC - APEXKingsland School DistrictOther School/CollegePine Island ElementaryPine Island High SchoolPine Island Middle SchoolRochester SchoolsSelfSelfReferral Source Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Referral Source Phone NumberReferral Source Email Address Enter Email Confirm Email Commitment StatusStay of CommitmentLegal IssuesService ProvidersGuardianNameAgencyPhone Number Representative PayeeNameAgencyPhone Number PsychiatristNameAgencyPhone Number TherapistNameAgencyPhone Number Primary Care ProviderNameAgencyPhone Number Case Manager/Social WorkerNameAgencyPhone Number Financial WorkerNameAgencyPhone Number Probation/Parole OfficerNameAgencyPhone Number Insurance/Income InformationSource of Income Social Security Income (SSI) Social Security Disability Income (SSDI) General Assistance Veteran's Administration (VA) Wage Health Insurance CompanyCounty of Financial ResponsibilityPlease Check Insurance Type Medicare Medicaid (MA) Commercial Insurance Employee Assistance Plan Insurance ID # or Medical Assistance PMI #Insurance Group #Assessment indicating a mental health diagnosis is required for IRTS referrals. Drop files here or Please upload a PDF file.Please attach current or recent notes/labs/medication list from current provider. Drop files here or Please upload a PDF file.Include current Release of Information. Drop files here or Please upload a PDF file.Would you like a copy of this form emailed to you? Enter Email Confirm Email Enter your email and we will send you a copy of the form.EmailThis field is for validation purposes and should be left unchanged. <noscript><iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_8' id='gform_ajax_frame_8' title='Ajax Frame'></noscript>This iframe contains the logic required to handle Ajax powered Gravity Forms.
