Billable Peer Support Referral Form

THIS FORM MUSY BE FILLED OUT COMPLETELY, PLEASE PUT N/A IF NOT APPLICABLE If any information is missing, this could delay services

Referrals must be faxed to 612-886-3940 or emailed to referrals@minnesotarecovery.org

Your Information

Participant Full Name

Phone

Date of Birth:

Month

Day

Year

Address

Gender (Select One)

Referral contact

Phone

Comprehensive Assessment Date

If participant has a PMAP/Insurance, please enter ALL information below

MCO Provider

Group #

Policy/Subscriber #

Medicaid ID/PMI

If participant has "straight MA" - only Medical Assistance, please enter ALL information below

Medicaid ID/PMI #

Referral must include a comprehensive assessment that indicates at least a risk rating of 1 in Dimension 4, 5, or 6 and must include a recommendation for Peer Services.

Primary SUD diagnosis (enter code i.e f11. 20, f12.20, etc.)

Service start date (enter the date the referral is sent - mm/dd/yyyy)

Check services provided (can only be 1:1 service but can attend a group with a participant)

EducationAttending recovery and other support groupsAccompany the client to appointments that support recoveryAssistance in accessing resourcesRecovery support to assist a person in the transition from treatmentAdvocacyMentoring

Please indicate Peer Recovery Specialist preference (if any): i.e. Male, Female, African American, Native etc. Due to availability, we cannot guarantee to accommodate all preferences.

Contact Information