Organizational Referrals to Elite Recovery

Make a Referral to Elite Recovery

Thank you for using our online referral form!

You may also contact our Program Support Specialist, Michelle Wolff at 612.719.4137 for assistance at any time during the referral process.

Feel free to also fax any documentation to 651.846.6745.

Name of Referring Party
First Last
Organization*
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client Name*
First Last
Client Date of Birth
Month
Day
Year
Client Phone*
Client Email
Insurance Provider*
Policy Holder Name*
Policy Holder Date of Birth
MM slash DD slash YYYY
Policy Number
Group Number
Reason for Referral
File Upload
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Please attach any assessments and/or releases of information to this form.

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