(612) 877-1089

Referral Form

Use this form is you are a case manager looking to refer a client.

Client First Name*

Client Last Name*

Client Address*

Address Line 1

City

State

Client Phone Number*

Alone Time?

Is the client Under Guardianship?*

Referrals will not be processed without guardianship documents.

Does the referral live in a provider controlled setting? (assisted living, group home, etc)*

Referral for*24 Hour Emergency AssistanceEmployment ServicesIHS w/TrainingNight Supervision

Reason for Referral — (please provide details). Your referral cannot be processed without additional details.*

Desired Hours of Services Per Week*

Medical Diagnosis

Mental Health Diagnosis

Case Manager Name*

Case Manager Phone Number*

Case Manager Email*

Thank you! Your submission has been received!

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Our mission is to help our community members achieve independence through compassionate, personalized health care.

Open Monday through Friday, 8:30am-5pm.
Available 24/7 for emergency client needs.

(612) 877-1089

5275 Edina Industrial Blvd
Edina, MN 55439

United Healing Network follows the State of Minnesota's COVID-19 protection recommendations. Click here to read more.