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Forms

Instructions for completing all forms for the Pediatric Mental Health Program

 

Step 1: Fill Out Form Completely

  • 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:

  • Email Submission:

    • Subject line suggestion: “[Form Type] Submission – [Patient’s Name and DOB]”

    • Email form to: DNeiss@redlakenation.org 

  • Fax Submission:​

    • Subject line suggestion: “[Form Type] Submission – [Patient’s Name and DOB]”

    • Fax form to: (612) 416-2093

  • In-person submission:

    • Drop off forms at Mino Bimaadiziwin Wellness Clinic with the Pediatric Front Desk Coordinator​.

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Step 3: Follow-Up

  • 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. 

  • 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

  • All medical records requests for pediatric clients can be sent via fax to 612-416-2093.  

  • Please include a release of information signed by the legal guardian.

Referral Form

Release of Information (ROI)

Transportation Request

Transportation Waiver - Child

Transportation Waiver - Adult

UCare Unaccompanied Minor

Blue Cross Unaccompanied Minor

Approved National Health Service Corps (NHSC) site and Pediatric Specialty site

 

©2022 by Pediatric Mental Health Program.

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