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Who are you completing this form for today?
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Myself
My client
My family member
A friend
Which service are being requested?
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SUD Only
SUD and Mental Health
Mental Health Therapy only
Client health insurance provider
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Please select a health insurance provider from this list.
If the provider is not listed please select "Other".
If the client is believed to have health insurance but the provider is unknown, please select 'unknown'.
If the client does not have health insurance please select "None".
Health Insurance Provider
Blue Cross Blue Shield of MN
UCare
HealthPartners
Medica
United Health Care
Humana
CBPs
Hennepin Health
Allina Health and Aetna
Other
Unknown
None
Preferred Partners Location
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Mpls- Men
St Paul- Men
St Paul- Women
Telehealth
Hibbing
Virginia, MN
Duluth
How did you hear about us?
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I have made previous referrals
Probation/Community Corrections
Family Member/Friend
Other Treatment Provider
Medical Provider
Housing Provider
Other
If you have any other information you think would be useful for us to know during the admissions process, please let us know here.
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