Online Referral Form – Premier Services

Use this secure referral form to refer an individual or organization, or to inquire about our services. A member of our team will follow up directly to gather additional information and guide you through the next steps.

Referral Source Information (Required)

We’ll use this to follow up and complete the referral securely.

Name

First Name

Last Name

Organization Name (if applicable)

Your Role or Relationship to the Individual/Entity Being Referred

Phone

(###)

###

####

Email

Preferred Method of Contact

Referral Type

Select the service(s) you are referring someone or an organization for.

Waiver Case Management

Rule 185 Case Management

Audit & Compliance Consulting

Not Sure (Please describe below)

Summary of Needs or Reason for Referral

Please briefly describe why you are making this referral or what services/supports may be needed.

Consent Acknowledgment

“I confirm that the individual or their authorized representative has consented to this referral and to being contacted by Premier.”

Email Us a Referral

If you prefer, you may also send referral information or questions to:

✉️ admin@premiercssmn.com

MAKE A REFERRAL

Online Referral Form – Premier Services

Premier Cultural and Social Services

Hours

Quick Links