2. Itasca County Rule 79 Adult Mental Health Referral
6. Referral Date
7. Client Social Security Number
9. Client's Name
10. Date of Birth
12. Qualifying Disability Code
14. Name
15. Phone Number
17. Address
19. City
20. State
21. Zip Code
23. Physician
24. Psychiatrist
26. Medicaid

    1. Yes
    2. No
    3. Not Eligible
27. Insurance Information PMI#
28. State MA
30. MN / IMCARE
31. SSI
32. IMCARE
33. MN CARE BLUE+
35. Private
37. Private Insurance
39. Policy Number
40. Group Number
42. Holder
43. Holder Date of Birth
45. Directions to Home
47. Referral Source Signature
48. Date
    Date

    Date
50. Client Signature
51. Date
    Date

    Date
53. Instructions
    Enclose a current diagnostic assessment that has been completed within the last 180 days.
55. Adult Mental Health is based upon eligibility criteria outlined in MN Statute 245.
57. Screenings for case management eligibility are completed twice weekly.
59. Incomplete referral forms will be returned for completion to the referring agency.
61. Itasca County Health and Human Services Resource Center
    1209 SE Second Avenue, grand Rapids, MN, 55744-3983
63. Phone: 218-327-2941, TDD: 218-327-5549
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