Associated Clinic of Psychology School and Home Based Therapy Referral Form

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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 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.

ARMHS

CTSS (Internal referrals only at this time)

Therapy

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

Open to Telehealth Services

In Person Services Only

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.

Yes

Unknown

N/A

Reason for referral *

Cats, dogs, or smoking in the client's home? *

Cat(s)

Dog(s)

Smoking

None

Unknown

Required

Is there any special considerations, such as cultural, gender and or time availibility needs?

Is the client enrolled in school in Dakota County? *

YES

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