Mental Health Health Referral Intake Form

Client Information


Can we text this number? YesNo
Can we use email? YesNo
Referring Information

Diagnostic Information

Staffing Preferences


Eligible clients must be at least 18 years of age, have a qualifying mental health diagnosis, and reside in Anoka, Dakota, Hennepin, Ramsey, Scott, Carver, or Washington counties. ARMHS recipients must have medical assistance or coverage through a prepaid medical assistance program (PMAP, for example, Blue Plus, Metropolitan Health Plan, etc.) In-home therapy recipients must have medical assistance, UCare/UCare SNBC, or Medica SNBC. Unfortunately, we do not accept Health Partners PMAP.

As soon as we receive a referral, Alliance Health Care staff will begin processing and verifying insurance coverage. If a client has “inactive” insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.