Adult Mental Health Case Management Referral Ramsey County Page 3
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3****** Please list specific SERVICE OBJECTIVES for Case Management to address *****
1)
2)
3)
Unless under civil commitment, case management is a voluntary service. Has the mental health
professional discussed this referral with individual being referred? Y / N
Is the person in agreement with receiving case management services? Y / N
This person has a functional impairment in the following area(s):
Mental Health
Mental Health Service
Use of Drugs and/or
Vocational
Symptoms
Needs
Alcohol
Functioning
Social Functioning
Interpersonal Skills
Self Care/ILS
Medical Health
Obtaining/Maintaining
Obtaining/Maintaining
Using Transportation
Financial Assistance
Housing
Other:
Please explain any boxes checked above:
Completed By:
Signature:
Printed Name:
Phone:
Name of Agency, Clinic or Hospital: __________________
Fax:
_________________
Date:
I qualify as a Mental Health Professional in the following field:
___ Advanced Practice Nurse
___ Psychiatrist
___ Psychology (LP, LPCC)
___ LICSW
___ LMFT
Please send this completed form and a Current Diagnostic Assessment to:
Ramsey County Case Management Intake
1919 University Avenue W #200. Saint Paul, MN 55104-3453
Phone: 651-266-7890
Fax: 651-266-7989
Please Note – completion of this process does not guarantee case management services
8-6-15
Page 3
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Parent category: Medical