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YOUR 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? (Currently, due to COVID impact on schooling, children must be 5 and under) *

Yes

No

Managed Care Organization? *

Yes

No

Insurance? *

Yes

No

* Prior to acceptance, a current Current Comprehensive Assessment or update must be completed. If you have a copy Comprehensive Assessment, it can be attached in the field below, or it may be faxed to Wellcome Manor Admissions Department, (507)218-2243.

Copy of Comprehensive Assessment:

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.

Wellcome Manor is a inpatient treatment center that helps women who are struggling with drug and alcohol addiction or substance abuse. Our center is located in Southern Minnesota near Mankato, in Garden City, MN....More

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114 Pleasant St W,
Garden City, MN 56034
1-866-559-3295
1-507-546-3295
1-507-218-2243

© 2021 Wellcome Manor Family Services