Refer a Client to WeCare in Central Minnesota

Service Type

What type of services are you seeking? *

Behavioral Health ARMHS, Outpatient Therapy, Assessments

PCA Services Personal Care Assistant

Adult Day Services Day Program

Patient Information

First Name *

Middle Name

Last Name *

Date of Birth *

Phone Number *

Mobile Phone *

Home Phone

Email Address

Address

Street Address

City

State

Zip Code

Demographics

Ethnicity

Gender Identification

Disability

Yes No Prefer not to say

Disability Type

Type *

Physical Mental Illness Developmental Substance Use Disorder

Guardian Information

Required for patients under 18 years of age

Guardian First Name

Guardian Last Name

Guardian Phone

Guardian Email

Relationship to Patient

Emergency Contact

Do you have Patient's Emergency contact or relative's info? *

Yes No

PCA Type

Select PCA Type *

Traditional PCA Choice

Waiver Type

Waiver Type *

CADI EW (Elderly Waiver) DD (Developmental Disability) BI (Brain Injury) None Other

Pet Information

Does patient have pets? *

Yes No

Transportation

Transportation Method *

Center Transportation Own Transportation

Insurance Information

MA# (Medicaid Number) *

Medicare

Yes No

Clinical Information

Primary Diagnosis

Recent History (Check all that apply over the past 12 months)

Self Injurious behavior Medication non-compliance High medical needs Aggressive/Violent behaviours Drug/Alcohol abuse Other

Services Interested In

Select all services of interest *

ARMHS (Adult Rehabilitative Mental Health Services) Outpatient Therapy Diagnostic Assessment Other

Has a Diagnostic Assessment within the last 12 months? *

Yes No Unknown

Please upload the Diagnostic Assessment document

Accepted formats: PDF, DOC, DOCX, JPG, PNG (max 10MB)

Would you like assistance from an MNSure Navigator?

Services Interested In

Select all services of interest *

Adult Day Care ARMHS Outpatient Therapy Counseling Other

Services Interested In

Select all services of interest *

Adult Day Care ARMHS Outpatient Therapy PCA Other

Services Interested In

Select all services of interest *

ARMHS Outpatient Therapy PCA Adult Day Services

Service Region

Preferred Service Region *

Twin Cities Metro

Saint Cloud Area

Winona Area

Referral Source

Referred by *

Referrer's information

Information about the person making this referral

Referrer's Name

First Name

Last Name

Phone Number

Email

Case Manager Information

If applicable

Case Manager Name

Case Manager Phone

Case Manager Email

Agency

Reason for Referral

Please describe the reason for this referral *

Referrals

Making a Referral

Which service are you referring for?

WeCare Referral

Referral Submitted Successfully!

Service Type

Patient Information

Address

Demographics

Disability Type

Guardian Information

Emergency Contact

PCA Type

Waiver Type

Pet Information

Transportation

Insurance Information

Clinical Information

Services Interested In

Services Interested In

Services Interested In

Services Interested In

Service Region

Referral Source

Referrer's information

Case Manager Information

Reason for Referral

Data Protection Consent

Referrals

Making a Referral

Which service are you referring for?

WeCare Referral

Referral Submitted Successfully!

Service Type

Patient Information

Address

Demographics

Disability Type

Guardian Information

Emergency Contact

PCA Type

Waiver Type

Pet Information

Transportation

Insurance Information

Clinical Information

Services Interested In

Services Interested In

Services Interested In

Services Interested In

Service Region

Referral Source

Referrer's information

Case Manager Information

Reason for Referral

Data Protection Consent

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