• Mon to Fri: 9:00am to 5:00pm

  • 651-528-7141

  • ...

  • 2056 Woodlane Drive Woodbury MN 55125

METROCARESERVICES

GENERAL REFERRAL FORM

GENERAL REFERRAL FORM

Referral Date:
Select a date
Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Middle Initial
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Date Of Birth
Field is required!
Field is required!
Gender
Field is required!
Field is required!
Race:
Field is required!
Field is required!
SSN:
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Reason(s) for Referral
Field is required!
Field is required!
Diagnosis (mental health and physical health) (please include diagnostic code as well as description)
Type Here
Field is required!
Field is required!

Special Needs

Are there any known cultural consideration needs
Field is required!
Field is required!
specify:
Field is required!
Field is required!
Is there any gender preference regarding the assigned staff?
Field is required!
Field is required!
If yes:
Field is required!
Field is required!
Allergies:
Field is required!
Field is required!
Other (be specific):
Type Here
Field is required!
Field is required!

Insurance Information

Primary insurance: (please check box)
Field is required!
Field is required!
Other
Field is required!
Field is required!
PMI Number:
PMI Number
Field is required!
Field is required!
Medical Assistance Number:
Medical Assistance Number
Field is required!
Field is required!
Primary Ins. #
Field is required!
Field is required!
Group #
Field is required!
Field is required!
Other insurance information
Field is required!
Field is required!

Does this person have: (mark if known; leave blank if unknown)

Waiver Case Manager? (If yes, enter information below)
Field is required!
Field is required!
Waiver Type:
Field is required!
Field is required!
Mental Health Case Manager? (If yes, enter information below)
Field is required!
Field is required!
Care Coordinator with primary clinic or insurance company? (If yes, enter information below)
Field is required!
Field is required!
Other: (Please specify type of provider such as physician, therapist, psychiatrist, child protection worker, etc.)
Provider Type
Field is required!
Field is required!

Mental Health Case Manager Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number:
Office number
Invalid phonenumber!
Invalid phonenumber!
Office Fax:
Field is required!
Field is required!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Waiver Case Manager Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number
Office number
Invalid phonenumber!
Invalid phonenumber!
Office Fax
Field is required!
Field is required!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Care Coordinator Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number:
Field is required!
Field is required!
Office Fax:
Field is required!
Field is required!
Cell number:
Cell number
Invalid phonenumber!
Invalid phonenumber!
Agency Name
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Legal Status & Legal Representative Contact Information

Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Fax Number
Field is required!
Field is required!
Email:
Field is required!
Field is required!

Primary Emergency Contact Information

First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Best Contact Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Second Contact Number:
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Relationship:
Field is required!
Field is required!
Email:
E-mail Address
Field is required!
Field is required!

Case Manager/ Other Provider Type Contact Information/ Referral Source

First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!
Office number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Office Fax:
Field is required!
Field is required!
Office number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

At time of referral, you may submit any other supporting documents (if you have them available): *Most current Diagnostic Assessment *Copy of Functional Assessment / LOCUS *County Case Plan *Crisis Plan *CSSP *IAPP *SMA

Referrals and copies of documents can be mailed, faxed, or e-mailed to: METRO CARE HUMAN SERVICES 2056 Woodlane Drive Woodbury MN 55125 Fax: (651) 528-7897 E-mail: info.intake@metrocareservicesmn.com Subject: Referral Form

Submit

Opening Hours Monday to Friday 9am - 5pm

Metro Care Human Services provides a variety of high-quality mental health counseling, including intervention, case management, and advocacy.

About Us

Our Services

Contact Info

2025 Website by Melo Multimedia LLC