Forms
Instructions for completing all forms for the Pediatric Mental Health Program
Step 1: Fill Out Form Completely
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Ensure that all sections of the form are legible, completed accurately and all contact information is current.
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* When submitting a referral form please also include a signed release of information if you are not the legal guardian.
Step 2: Submit the Form
After completing the form, choose one of the following submission methods:
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Email Submission:
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Subject line suggestion: “[Form Type] Submission – [Patient’s Name and DOB]”
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Email form to: DNeiss@redlakenation.org
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Fax Submission:​
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Subject line suggestion: “[Form Type] Submission – [Patient’s Name and DOB]”
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Fax form to: (612) 416-2093
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In-person submission:
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Drop off forms at Mino Bimaadiziwin Wellness Clinic with the Pediatric Front Desk Coordinator​.
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Step 3: Follow-Up
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After submitting a referral, within five business days, you will be contacted by the Pediatric Care Coordinator who will provide an update on an intake appointment. If our therapists are at capacity you may be placed on a waitlist and provided additional resources if needed.
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If you have any questions about a referral you have made or forms you have submitted please contact Danielle Neiss, Pediatric Care Coordinator, at dneiss@redlakenation.org or 651-396-3070.
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Medical Records
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All medical records requests for pediatric clients can be sent via fax to 612-416-2093.
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Please include a release of information signed by the legal guardian.