Referral Form

For information on our programs or to refer someone for services please follow link below. A staff member will be in touch with you within 1-2 business days.

If you have specific questions regarding LBSA services, please reach out to us at at intake@laurabaker.org or 507-645-8866.

Program of Interest

Participant Information

First Name: (required)

Last Name: (required)

Date of Birth:

Gender:

Pronouns:

Mailing Address:

Participant Phone Number:

Participant Email: (required)

PMI Number:

Diagnosis(s):

Communication Level:

Language:

Guardianship:

Type of Guardianship:

Contact Information

Guardian Name:

Guardian Phone Number:

Guardian Email:

Case Manager Name:

Case Manager Phone Number:

Case Manager Email:

Agency or County:

Additional Information

Waiver:

Waiver Type:

County of Waiver:

Additional Information:

Follow-Up Preferences

Who would you like us to follow-up with?: (required)

If other, provide name and contact:

Preferred Follow-Up Method: (required)