CTSS Referral Form

Child's Information

If your child attends one of these schools, CTSS services can be offered in-school: Forest Elementary, Meadow Lake Elementary, Plymouth Middle, Robbinsdale Cooper High School, Sandburg Middle. If your child lives in Hennepin or Anoka County, CTSS services can be offered in-home.

If a referral for School-Based Mental Health (SBMH) services has already been completed, a separate CTSS referral is not required when requesting both SBMH and CTSS services.

Child's First Name*

Child's Last Name*

Preferred Name

Identifying Gender*

Date of Birth*

Contact Information

*Please Note: A legal guardian is required to consent to services for clients under the age of 18 years old. If you are not the child's birth parent, or if there are any custody considerations, we require court or notarized documentation that indicates you have authority to medically consent to services. Please email this documentation to centralaccess@peopleincorporated.org.

Parent/Guardian Name*

Phone*

Email*

Relationship to Child*

Second Parent/Guardian Name

Phone

Email

Relationship to Child

Street*

City*

State*

Zip Code*

County*

Referral Information

Which CTSS Program are you wanting to refer this child to?*

If this referral is for a CTSS group, please specify which group:

Referent Name*

Referent Phone*

Referent Email*

Referent Role*

Referent's Employer or Organization

Summary of concerns & reason for referral*

Insurance Information

*This section is optional, but please note: To be eligible for CTSS services with People Incorporated, a client must have MA or a PMAP for their insurance coverage.

Insurance Provider & Member ID

Insurance Type

PMI (if relevant)

CAPTCHA

Child's Information

Contact Information

Referral Information

Insurance Information

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Programs

Residential Crisis Stabilization Services (RCS)

Intensive Residential Treatment Services (IRTS)

Residential Services

Outpatient Mental Health Clinics

Children & Youth Services

Community Outreach & Partnerships

Case Management