RCCMHC Online Referral Form

1

Is this an emergency, safety concern or crisis?* This field is required.For emergency, safety concerns or crises that need same-day response: dial 911 or call the Ramsey County Mobile Crisis Team 651-266-7878. Ramsey County Children’s Crisis Response Team is available 24/7 every day. They can see youth and families at school, at home, in-community or at 402 University E, St. Paul.

No, this is not a crisis.

Yes, this is a crisis.

No, but I have concerns that this may become a crisis situation. (RCCMHC will flag your referral as urgent, but you may also want to text us and request a consultation 800-565-2575.)

2

What is the referral source* This field is required.

Self Referral (I am a parent or caregiver)

County

Hospital or Inpatient

Provider or Family Service Agency

School

Other

3

RCCMHC offers FREE "Whole-Family" Support

Resource navigation
Therapy appointment setting and referrals
Care Team Coordination (school, county, primary care, local healers and providers)
Classes and programs or parents/caregivers
"Moodie Monday" skills groups for ages 6-11 and 12+
Resilience coaching and peer support
Leadership opportunities
Resource events- "one stop shopping"
All new families are eligible to receive free CALM toolkit supplies and a Family Care Organizer.
Our family support staff are mostly BIPOC. We speak English, Spanish, Somali, and Hmong. All of our staff have lived experience with youth mental health, trauma, and/or poverty.

4

RCCMHC Connects to Therapeutic Services

Individual or family therapy
Wide variety of cultural providers, specialty therapies etc.
Therapists meet with children and/or families in-clinic, virtually, or at home. With school permission, some therapists are able to meet in the school building (virtually or in-person).
Our member agencies commit to the care team process and work with us to reduce barriers.

5

Name of Primary CUSTODIAL Parent/Caregiver* This field is required.THIS WILL BE OUR PRIMARY CONTACT (You can add other custodial parents/caregivers later.)

First Name

Last Name

6

Language spoken by CUSTODIAL Parent/CaregiverPRIMARY CONTACT

7

Phone Number for CUSTODIAL Parent/CaregiverPRIMARY CONTACT

Please enter a valid phone number.

8

Email Address of CUSTODIAL Parent/CaregiverSkip if there is no email

example@example.com

9

Name, Phone, Email for other custodial parents/caregivers

10

Please list ALL youth that may need support. Please list NAME, AGE, and GRADE. Example: Wesley Jones 6 years old (First Grade)

11

Please add a SHORT description of the current challenge(s.)

12

Name of Referring Provider* This field is required.

First Name

Last Name

13

Email of Referring Provider* This field is required.leave blank if you do not have email

example@example.com

14

Phone Number of Referring Providerleave blank if you do not have a direct work phone number

Please enter a valid phone number.

16

Please select a hospital or inpatient system* This field is required.

Abbott NW Hospital (Inpatient)

Abbott NW Hospital (Emergency Department)

Children's Hospital (Emergency Department)

MHealth Fairview (Inpatient)

MHealth Fairview (Emergency Department)

PrairieCare Inpatient

Regions Hospital (Emergency Department)

United Hospital (Emergency Department)

Other

17

Please select a School District* This field is required.

Northeast Metro Intermediate District 916

MoundsView District621

Northeast Metro 916 Intermediate School District

North St Paul Maplewood Oakdale District 622

Roseville Area Schools District 623

Saint Paul Public Schools District 625

White Bear Lake Area Schools District 624

Other

18

Please type the name of your agency

19

To be eligible for services, youth must meet all 3 criteria.Please select all that apply

Child or teen lives in Ramsey County or attends a school district affiliated with Ramsey County.

At least one child or teen in the family is struggling with emotions/behaviors.

The child or teen would benefit from a "whole family" care-team approach. (i.e. youth from highly stressed families with complex needs or multi-system involvement, families experiencing barriers to service, underserved and marginalized families.)

20

Do any of these apply to your referral?* This field is required.Our staff may contact you for a professional consult before calling the family.

Intellectual or developmental disabilities are the primary concern.

Basic needs is the primary concern.

ONLY needs psychological assessment (Diagnostic Assessment, neuropsych, ADHD testing, etc.)

Adult mental health is the primary concern.

Caregiver speaks a language other than English, Spanish, or Somali.

None of these apply

21

Authorization/Release of Information

A signed Release of Information is not required to make this referral. However, it is EXPECTED that you discuss this referral with the CUSTODIAL parent/caregiver(s.) If you DO have a signed ROI, you can upload it in the next section.

During our intake, the custodial parent/caregiver will sign an RCCMHC Authorization to Exchange and Disclose Information. They will have the option to add school, county, or other agencies.

22

Have you discussed this referral with the CUSTODIAL parent/caregiver? Select ONE.This includes getting permission for RCCMHC to CALL, EMAIL and TEXT the parent/caregiver.

YES- I have verbal permisison to send this referral

YES- I have a signed Release of Information

Other

23

If you have a Release of Information (ROI), please upload it here

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

24

Next Steps- scheduling* This field is required.

I want RCCMHC to contact this referral.

I want to help the family schedule their first intake (the parent/caregiver must be with you to proceed with this option.)

25

Staff Notes- SHOW ON JOTFORM TABLEto be completed by RCCMHC staff only

26

Please submit your referral later

For emergency, safety concerns or crises that need same-day response: dial 911 or call the Ramsey County Mobile Crisis Team 651-266-7878. Ramsey County Children’s Crisis Response Team is available 24/7 every day. They can see youth and families at school, at home, in-community or at 402 University E, St. Paul.

27

Hello! Your family was referred to RCCMHC or you submit a self referral. This form will tell you about our services and help you set up an intake.

28

Most people call us their "collab family."

Our staff have lived experience with mental health, trauma, and/or poverty. We will support you without judgement. We will work hard to earn your trust so that we can partner together. If there is anything that we can do to make you feel welcome, please let us know.

29

RCCMHC offers FREE "Whole-Family" Support

Resource navigation
Therapy appointment setting and referrals
Care Team Coordination (school, county, primary care, local healers and providers)
Classes and programs or parents/caregivers
"Moodie Monday" skills groups for ages 6-11 and 12+
Resilience coaching and peer support
Leadership opportunities
Resource events- "one stop shopping"
All new families are eligible to receive free CALM toolkit supplies and a Family Care Organizer.
Our family support staff are mostly BIPOC. We speak English, Spanish, Somali, and Hmong. All of our staff have lived experience with youth mental health, trauma, and/or poverty.

30

RCCMHC Connects to Therapeutic Services

Individual or family therapy
Wide variety of cultural providers, specialty therapies etc.
Therapists meet with children and/or families in-clinic, virtually, or at home. With school permission, some therapists are able to meet in the school building (virtually or in-person).
Our member agencies commit to the care team process and work with us to reduce barriers.

31

Name of Primary CUSTODIAL Parent/Caregiver (scheduling)

First Name

Last Name

32

What services are you interested in?

Resource navigation for basic needs or other family services

Appointment setting and referrals for therapy or other therapeutic supports

Care Team coordination (helping your family's providers to work together)

Peer support and resilience coaching

Virtual classes and programs for adults

Virtual skills groups for kids/teens

Family programs and Resource events

33

Eligibility- Do you have at least one child or teen who is struggling with emotions or behaviors?* This field is required.

YES- I am the parent, foster parent or guardian of a child/teen who has a mental health diagnosis is struggling with emotions or behaviors that may put them at risk for a mental health diagnosis in the future

NO

Other

34

Eligibility- Does your child live or go to school in Ramsey County?* This field is required.

My child that is struggling with emotions/behaviors currently lives in Ramsey County

My child that is struggling with emotions/behaviors attends a school affiliated with Ramsey County

We are homeless but still getting some services in Ramsey County

Other

35

Cost: All RCCMHC services are free and voluntary. Referrals to external agencies may result in charges to your insurance/health care plan, co-pays or other fees. We will help you find services you can afford.* This field is required.