• Mon to Fri: 9:00am to 5:00pm

  • 651-528-7141

  • ...

  • 2056 Woodlane Drive Woodbury MN 55125

METROCARESERVICES

TREATMENT REFERRAL FORM

Internal Referral Form

Referral Source Information

Person Making Referral:
Full Name
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Date:
Select a date
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Referral Organization:
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Phone #:
Your Phonenumber
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Invalid phonenumber!
Office Contact Person:
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Fax #:
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Personal Information

Your First Name
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Your Middle Initial
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Your Last Name
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Date of Birth
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Gender
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Race
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SSN
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Your Address
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City
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Zipcode
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Phone Number
Your Phonenumber
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Invalid phonenumber!
Cell Number
Your Phonenumber
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Invalid phonenumber!
E-mail address
Your E-mail Address
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Reason for Referral request
Type Here
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Client referred for: (check one or more boxes below)

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Do you have a Current SUD or Rule 25 Assessment ( within the last 30 days)
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Previous Assessments
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Where/When
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Previous Treatments?
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Where/When
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Funding: Insurance

Primary insurance: (please check box)
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PMI Number
PMI Number
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Medical Assistance Number
Medical Assistance Number:
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Primary Ins. #
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Group #
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Other insurance information
Type Here
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Field is required!
CCDTF(Rule 25 Funding)
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County
County
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Worker’s Name who approved
Worker's Name
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Rule 25/Comprehensive Assessment

Previous Assessments dates/ company? Assessor /
Previous Assessments dates/ company? Assessor /
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Field is required!
Name of Program/Person
Name of Program/Person
Field is required!
Field is required!

Referrals can be e-mailed to: Deb Hagen E-mail: deb.hagen@metrocareservicesmn.com Subject: Substance Abuse Referral

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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.

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