Referral Form

Client's Full Name

Address

Phone

Client's pronouns

Alone Time? (if the client doesn't have alone time, MGH will not be able to meet their needs.)

Court Appointed/ Corporate Guardian? (Referrals will not be processed without guardianship documents.)

Desired Hours for Services (Put "N/A" for 24 hour emergency assistance services)

Does your client need a CPR certified Staff?

Does your client have a chronic illness that requires a treatment plan (i.e. epilepsy)?

Does your client have an active DNR/DNI (Health Care Directive)?

Does the referral live in a provider controlled setting? (Assisted living facility, group home, customized living, etc.)

Referral for:

Reason for Referral - IMPORTANT: Please provide specific details of the service needs of your client. Your referral cannot be processed without these additional details

Mental Health Diagnosis:

Medical Diagnosis:

Case Manager Name

Case Manager Phone Number

Case Manager Email Address

Please attach supporting documents * Supporting documents could be CSSP, MnChoices assessment, and any other supporting document of historical data

Referral Date