Lighthouse of Southern MN Referral Form

*Please note: if a family member has a mental health diagnosis, substance use history, or legal concerns they will not be excluded from admission.

Is this a referral for:

Our Men's House

Our Women's House

Email*

Client Legal Name*

Client Preferred Name*

Client Preferred Pronouns*

Number of Children

0

1

2

3

Option 5

Ages of Children

Client Phone Number*

Client Situation*

Has the resident/family resided in Steele County for more than 30 days? *

Yes

No

Does any member in the family have any known allergies? *

Yes

No

If yes, what are the allergies?

Does any family member have a mental health diagnosis?*

Yes

No

Mental Health Providers*

Mental Health Hospitalizations? *

Yes

No

Does any family member have a history of substance use? If yes, please explain: *

Does any family member have current or previous criminal history, including any arrests? If yes, please provide details: *

Are you aware if the resident has completed a VI-SPDAT/CE assessment?

Yes

No

Name of Person Making Referral *

Phone Number of Person Making Referral *

Are there any special needs, circumstances, or medical conditions? *

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