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Hennepin County, Minnesota
Anonymous
DART Referral (Diversion and Recovery Team)
Client Information
Provider Information
Behavioral Health History
Client name
Is this person homeless or has a recent chronic history of homelessness?
Yes
No
Where is this person currently?
Contact Information Unknown
Client contact information
Is this person aware of the referral?
Yes
No
Name of person making referral
Agency / Organization name (if applicable)
Contact information:
Phone number
Email address
Other involved providers
List MI/CD diagnoses
Known past treatment episodes
Emergency room visits, hospital admissions and/or detox visits in past 12 months (if known)
Is the person in treatment?
Yes
No
Unknown
Provider name
Level (if known)
Program admit date (if known)
Anticipated discharge date
Civil commitment?
Yes
No
Probation/Supervised release?
Yes
No
What assistance does this person need?
Please provide any other information that would be helpful for this referral
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