Hennepin County, Minnesota
DART Referral (Diversion and Recovery Team)
Behavioral Health History
Is this person homeless or has a recent chronic history of homelessness?
Where is this person currently?
Contact Information Unknown
Client contact information
Is this person aware of the referral?
Name of person making referral
Agency / Organization name (if applicable)
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?
Level (if known)
Program admit date (if known)
Anticipated discharge date
What assistance does this person need?
Please provide any other information that would be helpful for this referral
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