Associated Clinic of Psychology School and Home Based Therapy Referral Form
Thank you for your interest in Associated Clinic of Psychology. Please complete the following form. All fields with a red asterisk are required fields to be completed. If you have any questions please call 612-455-8643.
REFERRAL INFORMATION
Referring Person's First Name *
Referring Person's Last Name *
Referring Agency/School/Person *
Enter Agency name, School name, "Family", or "Friend"
Referring Person's Title: *
Example: School Counselor, Case Manager, Social Worker, Mother, Friend
Referring Person's Address (Street Address/Suite, City, Zip): *
Enter Agency/School address -OR- home address if Family/Friend.
Referring County *
Referring Person's Phone Number *
Referring Person's Fax Number *
Enter "x" for none
Referring Person's Email: *
Enter "x" for none
Requested Service(s) *
** 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.
Required
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 *
Cats, dogs, or smoking in the client's home? *
Required
Is there any special considerations, such as cultural, gender and or time availibility needs?
Is the client enrolled in school in Dakota County? *
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