Enter Agency name, School name, "Family", or "Friend"
Your answer
Referring Person's Title: *
Example: School Counselor, Case Manager, Social Worker, Mother, Friend
Your answer
Referring Person's Address (Street Address/Suite, City, Zip): *
Enter Agency/School address -OR- home address if Family/Friend.
Your answer
Referring County *
Choose
Unknown
Anoka
Carver
Dakota
Hennepin
Ramsey
Scott
Washington
Other
Referring Person's Phone Number *
Your answer
Referring Person's Fax Number *
Enter "x" for none
Your answer
Referring Person's Email: *
Enter "x" for none
Your answer
Requested Service(s) *
** Please note that ACP encourages a Therapy-First model for Community Based services. Clients being referred for ARMHS who do not currently have Therapy established will be screened for Therapy services prior to proceeding with ARMHS. Clients being referred for CTSS are required to be receiving Therapy services per DHS.
Required
Service Type *
*Please select "Open to Telehealth Services" if you/client are open to services being done via telehealth and/or in person; please select "In Person Services Only" if you/client are only requesting services be in person
Does client have Therapy services already established? (check N/A if requesting Therapy above) *
** Please note that ACP encourages a Therapy-First model for Community Based services. Clients being referred for ARMHS or CTSS who do not currently have Therapy established will be screened for Therapy services prior to proceeding with ARMHS or CTSS.
Reason for referral *
Your answer
Cats, dogs, or smoking in the client's home? *
Required
Is there any special considerations, such as cultural, gender and or time availibility needs?
Your answer
Is the client enrolled in school in Dakota County? *