Peace of Mind of Duluth ARMHS Referral
Thank you for considering Peace of Mind of Duluth for ARMHS Services.  The following form helps us determine eligibility.  Please fill out all required fields to help avoid any delays.  Questions:  call 218-580-9937
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Eligibility 
Eligible Members

To be eligible for ARMHS, MHCP members (Medical Assistance/MA) must meet all of the following criteria:

  • Be 18 years old or older
  • Have a primary diagnosis of a mental illness as determined by a Diagnostic Assessment
  • Have a completed level of care assessment
  • Have a significant impairment in functioning in three or more areas of the Functional Assessment domains specified in statute
    • Email address of person completing this form *
    How did you hear about us? *
    Full Legal Name (First, Middle, Last) of person being referred *
    Preferred Name
    Date of Birth *
    MM
    /
    DD
    /
    YYYY
    Address *
    Phone *
    Email address of person being referred (if different)
    What is the best way to reach you? *
    Birth Sex
    Clear selection
    Gender Identity
    Sexual Orientation
    Race
    Language(s)
    Marital Status
    Clear selection
    Employment Status
    Clear selection
    Insurance Provider *
    Insurance Member Number
    Guardian Name/Phone Number (if applicable)
    Person Making Referral (Name, phone, email) *
    Has the individual being referred been made aware of the referral?   *
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