Referral Form

Referral Form
Please make a referral by completing the following fields and clicking submit, or print off the form and fax to the client's preferred clinic location. If referring more than one client in the same family, please list all names on one form and only submit once.
Referring Name & Title
Referring Organization
Referring Phone Number
Referring Email Address
Referring Address
Patient Name*
Patient Gender
Patient Address*
Patient Phone Number*
Patient DOB*
Parent/Guardian Name (if applicable)
Preferred Location*
Insurance Type
Service*
Reason for Service
*Please Note: Records are Needed for referrals to ACT and IRTS.

Please send a recent Diagnotic Assessment, Psychiatric Evaluations, Medication Lists, and recent progress notes, along with any other pertinent information by fax to:

Northway IRTS: 320.529.4909

St Cloud ACT: 320.253.4179

Monticello ACT: 763.271.5350

Elk River ACT: 763.274.1165
Enter the message as it's shown*
This electronic message, including all attachments, is intended only for the use of the recipient(s) named above and may contain legally privileged and confidential information. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after its stated need has been fulfilled. If you received this message in error, you may not use, disclose, copy, or disseminate any of the information contained in this message. Please notify the sender by reply e-mail and destroy the original message including all attachments. Thank you for your cooperation.
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