ARMHS Referral Use this form to submit an ARMHS referral. Our team will get back to you shortly. Thank you! Is This a Self Referral? * Yes No Client Name * First Name Last Name Client Address * Client Email Client Phone Number * (###) ### #### Client Date of Birth * MM DD YYYY Client PMI (If Known) Client Gender Emergency Contact Information First Name Last Name Phone (###) ### #### Does the client receive medical assistance? Yes No If so, through which medical insurance provider? Ucare Health Partners Blue Cross Blue Shield Medica Hennepin Health United Healthcare MA Other What is the client's current living arrangement? Own housing Lease Mortgage Roommate Family/friends due to economic hardship Service provider Foster care Group home Hospital/Treatment/Detox/Nursing home Jail/Prison/Juvenil Detention Hotel/Motel Emergency shelter Place not meant for housing Others As your ARMHS provider, what can we help you with? We are able to work with you with almost any issue that is impacted by mental health symptoms. * Navigating and benefiting from medical, dental, mental health, and substance use services Handling basic life tasks and daily living activities or getting needed services Finding and maintaining stable housing, financial supports, and budgeting Feeling safe in the community, getting food/goods from the store, and handling transportation Developing healthy relationships and communication skills Overcoming barriers to pursuing education or work other - - - - - - - - - - - - - - - Only complete the fields below if you are making a referral on behalf of a client - - - - - - - - - - - - - - - - - - - - . Referrer's Name First Name Last Name Referrer's Phone Number (###) ### #### Referrer's Email Referrer's Organization & Job Title We’ve received your referral. You will hear from our team soon!
