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Community Mental Health & Wellness Services Referral Form

Community Mental Health & Wellness Services Referral Form

If the client is in immediate crisis or suicidal Call 911 or Adult Crisis Response 651-266-7900; Children's Crisis Response 651-266-7878.

Referred By

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Client Information

Name(Required)
MM slash DD slash YYYY

Parent/Guardian Information

Parent/Legal Guardian Information(Required)
Parent/Guardian Name(s)(Required)

English Fluency

Client

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Parent/Guardian

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Insurance Provider

What type of services are you referring the client for?

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Consent to Release Information

  • I consent to have my clinic share the information on this form with Wilder’s Mental Health Services and that they will contact the identified caregiver.
  • I consent to have the Wilder Foundation provide feedback to my clinic about the status of this referral for mental health.
  • I understand I may refuse to sign (and can revoke) this referral and consent, except to the extent that action has already been taken in reliance on this consent.
  • I understand that my clinic may not condition my treatment/services or payment of my bills on my decision to sign this referral and consent form.
  • I understand that when the information specified on this form is sent to the Wilder Foundation’s Mental Health Services, they have agreed not to re-disclose the information to any third party other than this clinic and to protect the privacy of this information consistent with state and federal privacy laws.
  • I agree that a photocopy of this form is as valid as the original.
  • I understand that, upon my request, I will receive a copy of this signed form.
  • I have read and agree to the terms above.
Clear Signature
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This field is for validation purposes and should be left unchanged.

NOTE: Please let the client and parents(s)/guardian(s) know that you have made this referral and that we will be contacting them to schedule an appointment. Most clients begin by having a diagnostic assessment appointment with one of our mental health clinicians in order to assess the client’s current mental health and service needs and discuss any concerns with parents/guardians. As always, we appreciate the opportunity to work with you and look forward to our collaboration.

Wilder
451 Lexington Parkway N
St. Paul, MN 55104

651-280-2000

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