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Therapeutic Services Agency, Inc.

Online Form

Completed by a referral source (school contact, clinician, or other provider) to refer a client to TSA's Day Treatment program at the Pine City or North Branch location.

Prefer paper? Download the PDF version All forms
Location
Location
Client Information
Client’s Race

Check All That Apply

Referral Source Information
School Information
IEP (circle one)
504Plan
DA or Psych Evaluation Complete
Please attach current Assessment to Referral and/or sign the attached Release of Information (ROI) for TSA to obtain. Delay in receiving will delay intake.
Addendum Completed as Needed
Mental Health Providers
Check all that apply and provide name of provider
Insurance Information
Custody
Parent’s Marital Status
Parent/Main Caregiver Information
In Case of an Emergency Contact
Others Providers Involved
Others Providers Involved
NameRoleWork NumberEmail
Medical & Transportation
Transportation Requirement (check required)

All children under age 8 must ride in booster seat unless the child is 4’9’’ or taller. 12 years and under must ride in back seat.

Transportation Needed
Clinical Information
Download the PDF instead

Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.