Patient Referral Form

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Please Select Clinic for Referral*

For Red Lake Clinic:

Please do NOT fill out this form. Instead, please call 218-679-0225 for more information.

For Cass Lake Clinic:

Please do NOT fill out this form. Instead, please call 218-335-3248 for more information.

Who Is Submitting This Referral?*

Name of Referring Organization/Agency*

Name of Referring Staff & Their Title/Role*

Contact Information for Referring Staff*

Name*

First Last

Phone*

Alternate Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

MM slash DD slash YYYY

OB Provider (if applicable)

Primary Care Provider (if applicable)

Due Date

MM slash DD slash YYYY

Tribal Affiliation (if applicable)

County You Live In

Reason(s) for Referral*

Home Visiting Services

Pregnancy/Post Partum Care

Transportation

Behavioral/Mental Health

Substance Use

Housing

Birth Support

Items for Baby

Prenatal/Childbirth Education

Food/Nutrition

Newborn/Pediatric Care

Breastfeeding/Lactation Support

Safety/Intimate Partner Violence

WIC/Food Assistance

Cultural Care

Health Insurance/Financial

Commercial Tobacco Cessation

Chronic Medical Condition (specify) e.g. Diabetes, High Blood Pressure

Other (specify)

Check all that apply

Please Specify Here:

Additonal Notes

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Programs

OB Care Coordination
Transportation Assistance
Family Home Visiting
Pregnancy Care & Education
Virtual Care
Other Support Services

Service Area Counties

Beltrami
Clearwater
Cass
Koochiching
Hubbard
Itasca

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