Peer Recovery Support Referral Form

Please Choose the Location

Saint Paul

THIS FORM MUST BE FILLED OUT COMPLETELY, PLEASE PUT N/A IF NOT APPLICABLE If any information is missing, this could delay services
Referrals must be faxed to 612-886-3940 or emailed to referrals@minnesotarecovery.org

Referral Name(Required)

First Name Last Name

Phone Number(Required)

Please enter a valid phone number.

Date of Birth(Required)

Gender(Required)

Date of Comprehensive Assessment

If applicable please fax or email comprehensive Assessments to

Fax#: (612) 886-3940 or Email: referrals@minnesotarecovery.org

Referral Contact

Referral Phone Number

Please enter a valid phone number.

If participant has a PMAP/Insurance, please enter ALL information below

MCO Provider

Group #

Policy/Subscriber #

Medicaid ID/PMI#

If participant has "straight MA" - only Medical Assistance, please enter ALL information below

Medicaid ID/PMI #

Referral must include a comprehensive assessment that indicates at least a risk rating of 1 in Dimension 4, 5, or 6 and must include a recommendation for Peer Services.

Primary SUD diagnosis (enter code i.e. f11. 20, f12.20, etc.)

Service start date (enter the date the referral is sent - mm/dd/yyyy)

Check services provided (can only be 1:1 service but can attend a group with a participant)

Education

Attending recovery and other support groups

Accompany the client to appointments that support recovery

Assistance in accessing resources

Recovery support to assist a person in the transition from treatment

Advocacy

Mentoring

Other

Please indicate Peer Recovery Specialist preference (if any): i.e. Male, Female, African American, Native etc. Due to availability, we cannot guarantee to accommodate all preferences.

Peer Recovery Support Referral Form

If applicable please fax or email comprehensive Assessments to

If participant has a PMAP/Insurance, please enter ALL information below

If participant has "straight MA" - only Medical Assistance, please enter ALL information below

Referral must include a comprehensive assessment that indicates at least a risk rating of 1 in Dimension 4, 5, or 6 and must include a recommendation for Peer Services.

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