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Self Referral

Phone

YOUR DETAILS

First name: *

Last name: *

Email Address *

Phone: *

Describe Current Situation: *

Do you have insurance? *

Yes

No

Have you had a Comprehensive Assessment (Substance Use Disorder Evaluation) Completed? *

Yes

No

Are you pregnant? *

Yes

No

Are you an IV user? *

Yes

No

Are you planning on bringing any children (Sorry, due to COVID and its impact on schooling, children must be age 5 or younger) to treatment? *

Yes

No

* Prior to acceptance, a current Comprehensive Assessment or update must be completed. If you have a copy of your 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 Your Comprehensive Assessment:

All clients will be scheduled for a telephone screening between the hours of 8:00 AM and 4:30 PM. *

Thank you for your interest in Wellcome Manor. An Admissions Representative will contact you within one 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