Order NumberYOUR DETAILS First Name: * Last Name: * Email Address: * Phone: * Organization: Association With The Referent: * Referent First Name: Referent Last Name: Referent Phone: Describe Current Situation: * Is Referent Pregnant? * Yes No Is Referent an IV user? * Yes No Does Referent Have Children? * Yes No CCDTF? * Yes No Managed Care Organization? * Yes No Insurance? * Yes No * Prior to acceptance, a current Rule 25 CD evaluation or update must be completed. If you have a copy of your Rule 25 CD evaluation, it can be attached in the field below, or it may be faxed to Wellcome Manor Admissions Department, (507)218-2243. Copy of Your Rule 25 CD Evaluation: All Referents will be scheduled for a telephone screening. *Thank you for your interest in Wellcome Manor. An Admissions Representative will contact you the following business day. If everything is correct, press SEND.