Marriage & Family Health Services Admissions

MIKAN/MIGISI CHILD/ADOLESCENT THERAPEUTIC DAY TREATMENT PROGRAMS

Referral Process:

1. When a child/teen has been identified as one who could benefit from therapeutic day treatment, the referral source (parent, teacher, social worker, school administrator, mental health professional, physician, etc.) informs the parent of the opportunity to participate in Mikan/Migisi. During this phone conversation/meeting, the referring individual will obtain the parent's permission for Marriage & Family Health Services to contact them. Neither the referral nor the intake obligates the family or school in any way. The purpose of the contact will be to arrange for an interview to determine whether or not their child would benefit from the program as well as to learn about the content of the program

2. Once the family and student have been informed about Mikan/Migisi and have agreed to an interview, the Mikan/Migisi referral form is completed and faxed or mailed to Marriage & Family Health Services (Fax # 832-0771). The parents are informed that a staff member from Mikan/Migisi will be contacting them to set up an appointment in the near future. When we receive the referral, one of our staff members will set the appointment with the family. The referral source may be identified as a point of contact and can be included in the treatment planning for their particular child.

3. Please feel free to contact us at our business office should you have any questions.

MIKAN/MIGISI DAY TREATMENT PROGRAM Interagency Referral Form for Day Treatment Assessment Download Interagency Referral Form for Day Treatment Assessment
Client's Name:			Today's Date:
Address:			Date of Birth:
			Phone:

Purpose of Referral:	Mikan Day Treatment Program	General Counseling
	Adolescent Anger Management Program	Other
	Adolescent In-Home Treatment

Goals for Treatment/Counseling:

Funding Source:	Private Insurance	Private Pay	BadgerCare Plus Benchmark
	County Funded	School Funded	BadgerCare Plus Standard

Name of Parents/Guardian:
Do They Support the Referral? Why?
Willing to Participate in Treatment/Therapy? Yes No
Parent's Address (if different):
Phone:

Referring Person:
Address:
Phone:

Case Manager Involved:

Follow-up Status:
Parent has agreed to program/counseling services. The initial meeting will be on
Parent did not agree to counseling. Plan:

CC:	County Human Services
	Marriage & Family Health Services
	Parent/Guardian
	Counselors Personal File - School District
	Social Worker/Referral Source

Main Office:
2925 Mondovi Road, Eau Claire, WI 54701 Phone # (715) 832-0238 Fax # 832-0771
405 Island St., Chippewa Falls, WI 54729 Phone # (715) 726-9208
905 7^TH Ave. West, Durand, WI 54736 Phone # (715) 672-8585
612 East Worden Avenue, Ladysmith, WI 54848 Phone # (715) 532-0632
501 S. Cherry Avenue Ste 5, Marshfield, WI 54449 Phone # (715) 486-8302
250 Buffalo St., Mondovi, WI 54755 Phone # (715) 926-5886
1107 Heart Island Pkwy, Rice Lake, WI 54868 Phone # (715) 736-KIDS (5437)

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