Welcome!
Summit ReEntry is a 6 bed Intensive Residential Treatment Service (IRTS) for adult men located in the Metro Area. If you have any questions about our program or difficulty completing this form, please call 612-600-4575.
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Email *
SUBMITTING A NEW IRTS REFERRAL:
Please send most recent hospital records, Diagnostic Assessment (DA), Functional Assessment (FA), Level of Care Utilization System (LOCUS) and other relevant collateral to Admissions@SummitReEntry.com for admission consideration.
Where did you hear about Summit ReEntry?
Client's Full Legal Name *
Client's Preferred Name & Pronouns *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Phone Number
Client Email Address *
Referent/Provider Contact Information:
1. Full Name
2. Phone, Email, and/or Fax
3. Job Title
4. Agency/Organization
 *
Preferred Communication Method(s) *
Required
Which location do you prefer?
What is the planned admission timeline?
Mental Health Diagnosis(es) *
Physical & Biomedical Diagnosis(es) *
Prescriptions:
1. Medication Names
2. Doses
3. Dosing Schedule
4. Related diagnosis or condition

Please note if any prescriptions have been mismanaged or abused. 
 *
Legal Supervision *
Client's Primary Goals for Intensive Residential Mental Health Treatment *
Eligibility Checklist *
Required
Treatment & Supervision Needs
Current Living Arrangement & Location *
MN Medical Assistance Member ID/PMI: *
Document(s) Completed and Emailed to Admissions@SummitReEntry.com for Admission Consideration: *
Required
Any additional context for us to consider?
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