The Therapist PLC | Counseling & Life Coaching in Brainerd, MN

Instructions

Please complete all required fields in this referral form with accurate and up-to-date information. Once you have filled it out, click Submit at the bottom of the page. You will receive confirmation that your referral has been submitted, and our team will follow up with you according to the process outlined below.

Date / Time *

REFERRAL INFORMATION

Name *

First

Last

Organization/Agency *

County *

Phone *

Fax (if applicable)

Email *

CLIENT INFORMATION

Name *

First

Last

Date of Birth

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

LEGAL / CIVIL STATUS

Civil Commitment

Yes
No

Currently Incarcerated

Yes
No

Facility Name & Location

FUNDING SOURCE

Please select one

AMHI Contract/Grant
Insurance (if insurance please complete information below)

Please Indicate Insurance Provider

Instructions Process SERVICE

Policy #

Group #

REQUESTED SERVICE INFORMATION

Description of Requested Service *

Referral Follow-Up Process

You will receive confirmation once this form is submitted. We will also notify you that we received the referral. Our team will contact the client within 24–48 hours and follow up with you once they are reached, whether they are seen or not, with any recommendations.