Referral Instructions

Please fill out all sections that apply as completely as possible.  Items marked with * are required in order to submit the referral.  If you have related documents to send us, there is a place to attach files at the end of the referral form.  When complete, type in the Captcha code and hit the "Submit" button at the very bottom of the form to send everything to us securely.  If you have any questions, please call us for assistance (952-921-8334).  If you change your mind, simply hit the "Cancel Referral" button above to return to our website.

Please tell us who is filling out this referral. Provide name and phone here, and details below in the appropriate section.

Please tell us what programs you might be interested in and believe you are eligible for. (We will help determine any and all applicable programs when we call back.)

If interested in the Technology for HOME (T4H) program, please provide the following information

Person Receiving Services (information)

Select a Diagnosis Category in the drop-down lists, then add the specific ICD-10 Code in the adjacent box.

Case Manager (if applicable)

Voc Rehab Counselor (if applicable)

Guardian (if applicable)

2nd Guardian (if applicable)

Please provide contact information for the Person's Physician

Other Contacts (if any)