Online Referral Form

If you're a healthcare provider, community member, or loved one concerned about someone struggling with addiction, our online referral form offers a straightforward way to connect individuals to our services.

Referral Process:

Secure Submission: Provide the necessary information about the individual in need through our confidential Referral Form.
Follow-Up: Our team will review the referral promptly and reach out to the referred individual to offer support and discuss available services.

Who Can Refer:

Healthcare professionals
Family members
Community members

Who are you completing this form for today?

If you are referring someone, please tell us your name, origin of referral and a call back number.

Please fill this out only if you are referring someone else.

Name

First Name

Last Name

Phone Number

(###)

###

####

Email Address

Date of Birth

YYYY

Which service are being requested?

Health insurance provider

Please select a health insurance provider from this list. If the provider is not listed please select "Other". If the client is believed to have health insurance but the provider is unknown, please select 'unknown'. If the client does not have health insurance please select "None".

Where are you located?

Twin Cities

Saint Cloud

Rochester

Duluth

Other

If you clicked other, what city are you located in?

How did you hear about us?

If you have any other information you think would be useful for us to know during the admissions process, please let us know here.