CIP ARMHS Program

Referral Form

ARMHS Programs Referral Form

**This completed form can be faxed Attn: Shayla Eubanks, Lead Service Coordinator at 612-547-0556 or

e-mailed to ; (612) 362-4452.

Referred by: Self-referral / Phone number:
How do you know this individual?

Personal Information

Client’s Name:
Does client require an interpreter? What language?
SS#: / DOB: / Working Phone number:
Address:
City: / Zip code:
Insurance/PMI/MA#:
Spend down? Yes No If yes, has the client agreed to pay the spend down for ARMHS? Yes No
*See attached form to be completed for each client referral
Mental and Physical Health concerns:
Emergency Contact (relationship):

Team Members

A psychiatrist? Name: ______Clinic/Agency: ______
A therapist? Name: ______Clinic/Agency: ______
A Care Coordinator? Name: ______Clinic/Agency: ______
A CADI/TBI/Elderly Waiver Case Manager? Name: ______Agency: ______
A rep-payee? Name: ______Contact info: ______
Other provider? ______

Referral

Reason for referral/Goals:
Does this client have any history of violent behavior and/or criminal history? Yes No
Describe:
Are there any known spiritual or cultural considerations? Yes No
Describe:
Are there any safety concerns present in the home, including bedbug infestation? Yes No
If yes, provide the date of eradication treatment:
Describe:
Is there a gender preference regarding the assigned staff? No Male Female
Any other relevant information:

Client Agreement for Payment of Medical Spend down

Client Name: ______Date: ______

I understand that I have a Medical Spend down in the amount of $ ______per month.

Once this amount is satisfied, my medical psychiatrist services will be completely covered.

(This amount does not include any co-payments that I may have for medication).

I will use this service of a representative payee:

Yes

If yes, the Rep Payee is, Name: ______

Address: ______

______

I agree to pay CIP my monthly spend down amount and I understand that if payment is not made to CIP; my services may be terminated.

______

Signature of Client Date

NA—Client does not have a spend down

Return to:

Community Involvement Programs

1600 Broadway Street NE

Minneapolis, MN 55413

*Fax: (612) 547-0556

Revised: 8/2015