• 2415 Emerson Ave South, Suite 204 Minneapolis, MN 55405
Call: 952.222.6969

Referrals

METROPOLITAN HUMAN RESOURCES REFERRAL FORM

*Referral Form must be completed in full before MHR can process referral*

Personal Information
Primary Emergency Contact Information
Special Needs
Insurance Information
Level of Need
Care Preferences
Does this person have: (mark if known; leave blank if unknown)
Mental Health Case Manager Information
Waiver Case Manager Information
Care Coordinator Information
Legal Status & Legal Representative Contact Information
Primary Emergency Contact Information
Case Manager/ Other Provider Type Contact Information/ Referral Source
PLEASE BE ADVISED: If this person fails to respond to MHR HSS Specialists on 3 or more occasions in a month, a 30-day termination notice will be served.
At time of referral, you may submit any other supporting documents (if you have them available): *Most current Diagnostic Assessment *Copy of Functional Assessment / LOCUS *County Case Plan *Crisis Plan *etc.
One thing concrete in life is the need for sustainable housing, interpreter services and social service resources to create memories and have a prosperous future ahead.

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Contact Info

Phone

952.222.6969

Fax

952.222.7270

NPI:

1821717844

Email

info@metropolitanhumanre
sources.com

Address

2415 Emerson Ave South, Suite 204 Minneapolis, MN 55405

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