Submit a Referral

Click here to Submit an in-office Therapy Referral

To make a referral, please complete the following form. A member of the Ellie team will be in touch within 1 business day.






Full Name

Phone Number

Email

Address

DOB

This is for maternal mental health

There are currently divorce or custody issues/concerns

What days/times work best?

Preferred Office Location:
LakevilleRichfieldWoodburySt. PaulAny

Insurance Company
* Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Group Number (Optional)

ID Number (Optional)

Therapist Gender Preference
MaleFemaleNo Preference

Previous/Current Diagnosis (if applicable)

How do you prefer we contact you? (email, phone, text, etc.)

Would you also like to talk to someone about medication options?
YesNo

Comments/Preferences

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.

Click here to Submit an IN-HOME Therapy Referral

To make an in-home therapy referral, please complete the following form. A member of the Ellie team will be in touch within 1 business day.






Full Name

Phone Number

Email

Address

DOB

This is for maternal mental health

Insurance Company
* Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Group Number (Optional)

ID Number (Optional)

Therapist Gender Preference
MaleFemale

Previous/Current Diagnosis (if applicable)

Referring Party: Please include your contact information:

Comments/Preferences

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.

Click here to Submit a Medication Management Referral

To make a medication management referral, please complete the following form. A member of the Ellie team will be in touch within 1 business day.






Full Name

Your Email

Phone Number

Address

DOB

I am currently attending therapy

Are you between the ages of 16 and 65 years old?

Are you currently pregnant or trying to become pregnant?

Are you currently or inquiring about taking *benzodiazepines, methadone, and/or suboxone?

Are you currently receiving chemo or radiation therapy, or taking any immunosuppressant medication?

Previous/Current Diagnosis (if applicable):

Do you have any chronic medical problems involving:
Liver (Hepatic impairment)Kidney (Renal impairment, Dialysis)Heart (Cardiac impairment, Heart attack, Stroke)Neuro (TBI, Epilepsy, Seizures)

List all others if not noted above:

Current medications (prescribed and OTC):

Preferred Office Location:
WoodburySt. PaulAny

Insurance Provider
*Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Insurance Group #

Insurance Member ID

Comments/Preferences

As soon as we receive a referral, Ellie staff will begin processing and verifying.

Click here to Submit an ARMHS referral






Your Name

Your Email

Client Name

DOB

This is for maternal mental health

Referral Date

Sex

SSN

PMI#

Insurance Provider
* Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Insurance Member ID

Insurance Group #

Age

Full Address

County

Phone

Legal Guardian
YesNo

If yes, Guardian Name

Number

Social Worker

Phone Number

Diagnosis

Language Preference

Interpreter Needed?
YesNo

Gender

Availability

Does the client smoke? If so, do they smoke in their home?

Does the client have pets? If so, what kind?

Referring Party: Please include your contact information:

Any additional information to help find a good match for an ARMHS practitioner please write below:

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.

Click here to Submit a CTSS referral






Your Name (referring person)

Your Email (referring person)

Client Name

DOB

Referral Date

Sex

PMI#

Insurance Provider
* Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Insurance Member ID

Insurance Group #

Age

Legal Guardian
YesNo

If yes, Guardian Name

Guardian Phone

Full Address

County

Social Worker

Phone Number

Diagnosis

Language Preference

Interpreter Needed?
YesNo

Gender

Availability

What kind of struggles is this child having? Why are CTSS services being considered?

How might skills work help this child?

What other services is this child currently receiving (psychiatry, therapy, day treatment, case management, etc.)?

Briefly note any family concerns::

Does the client/family have pets? If so, what kind?

Any additional information to help find a good match for an CTSS practitioner please write below:

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.

Click here to Submit a School-Based referral






Your Name (Referring Party)

Your Number (Referring Party)

Your Email (Referring Party)

Child's Full Name

DOB

Guardian(s) Name

Guardian(s) phone number

Email (if applicable)

Address

Insurance Company
* Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Group Number (Optional)

ID Number (Optional)

Therapist Gender Preference
MaleFemale

Previous/Current Diagnosis (if applicable)

School Location (which school is this child being treated at?):

School contact or social worker:

Reason for Referral

Any additional comments or concerns that would be helpful to know about?

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.