Hope Realized

Making an Appointment or Referral

We have amazing referral staff who are ready to take your call and assist with getting services started and scheduling an appointment. Please call them at the extension listed below:

(320) 629-7600 Ext. 7606

If you are making a referral for a Foster Care Based Treatment Program, please contact:

                                        Wendy Rude Pangerl, Licensing Social Worker at 320-629-7816

Referral staff may have you complete a referral form which can be found below. Please fax completed forms to 651-925-0071.

• Foster Care Based Treatment Programs Referral Form
• Outpatient & In-Home Family Based Services Referral Form
• Day Treatment Referral Form
• School Based Mental Health Services Referral Form
• Deaf and Hard of Hearing Services Referral Form

If you are interested in making a referral for a program or service that is not listed above, we encourage you to call our referral team. 

Intake Forms

Foster Care Based Treatment Programs

After making a referral and being accepted into one of our Foster Care Based Treatment Programs (Child and Adolescent Treatment Programs, Teen Mom & Child, Full Family Care), you will be asked to complete the following forms:

• Billing Release
• Cover Sheet - Foster Care Based Programs 
• Consent for Release of Information
• Health History  
• Intake Interview  
• Internet Computer Use Permission Form 
• MCCCA Consent SDRS Form 
• Medical Insurance Form                                                                                                                          
• Medical, Psychiatric, Dental and Optical Permit 
• Missing Person Report 
• Multiple Consent Forms Combined    
• Prescription Information 
• Previous Placement Services 
• Referring Worker Checklist 
• Substitute Care and Respite Care Notice 
• Description of Agency Program and Services – MN Rule, Part 9545.0815

Outpatient Services and In-Home Family Based Services

Below are links to common intake forms we ask clients to complete prior to the start of services. If you are able to, please print off and complete the forms relevant to your situation. If you do not have access to a printer, please plan to arrive 15-20 minutes early to your first appointment and our administrative staff will be happy to provide you with the appropriate forms. 

• Billing Release - Completed by all clients (for parent/guardian of client under 18 years old). *If you are a county worker, please complete the Billing Release prior to scheduling an appointment for your client. 
• Adult History Questionnaire - Completed by adult client who is receiving services for themselves
• Child/Adolescent History Questionnaire - Completed by parent/guardian for their child under 18 years old
• Consent for Release of Information - Completed by all clients (or parent/guardian of client under 18 years old). *If you are a county worker, please complete the Consent for Release of Information prior to scheduling an appointment for your client. 
• Notice of Privacy Practice (Form 23000) - Information for client's personal records
• Strengths and Difficulties Questionnaire (SDQ) - Completed by client or parent/guardian (if client is 17 or under).
  • SDQ Completed by parent of a child ages 6-10
  • SDQ Completed by a parent of a youth ages 11-17
  • SDQ Completed by a youth ages 11-17
  • SDQ Self-Report ages 18-20

At this time, only intake forms for our Foster Care Based Treatment Programs, Outpatient services and In-Home Family Based Services are accessible online. Forms for other TSA programs and services will be discussed and available to you at your first appointment.