Get Started Today

To get started with our clinical services, please complete this form with accurate and detailed information. This helps our intake team understand needs and connect each person with the most appropriate care. If you have questions while completing the form, please contact us for assistance at 651-242-5540.

Referring providers: Please send additional referral materials and comprehensive assessment for the client you are referring. Fax to 651-209-6341

If interested in Supportive Housing use this application:

Supportive Housing

Clinical Intake Request Form

Who are you completing this form for today?(Required)

Client's first name(Required)

Please enter the first name of the person you are filling the form out on behalf of

Client's last name(Required)

Please enter the last name of the person you are filling the form out on behalf of

Client's phone number(Required)

Client date of birth(Required)

Your first name(Required)

Please enter the name of the person filling out this form on behalf of the client.

Your last name(Required)

Please enter the name of the person filling out this form on behalf of the client.

Your Phone(Required)

Your email address(Required)

The name of your company, or your organization(Required)

Your company or organization's website(Required)

Your professional title(Required)

What Wayside Recovery service is being requested?(Required)

Client health insurance provider(Required)

Please select a health insurance provider from this list. If the provider is not listed please select "Other". If the client is believed to have health insurance but the provider is unknown, please select 'unknown'. If the client does not have health insurance please select "None".

If you have any other information you think would be useful for us to know during the admissions process, please let us know here.

Please print your name below as a signature to confirm the information entered above is accurate.(Required)

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