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By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
By electronically signing this you acknowledge that you have spoken to the Parent/ Legal guardian and have a signed release on file to submit a referral.
* Attach a diagnostic assessment that has been completed in the last 180 days.
* Children's Mental Health Case Management is based upon eligibility outlined in MN Statute 245.4871, Subd.6
*Screening for Case Management eligibility is competed twice a week.
* INCOMPETE REFERRAL FORMS WILL BE RETURNED FOR COMPLETION TO THE REFERRING AGNECY.
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