2. Referral Source Information
4. Referral Source/Person completing form*

   1. Client
   2. Crow Wing County Employee
   3. Other
5. Is client aware of the referral?

   1. Yes
   2. No
   3. Unknown
6. Relationship to Client
7. Agency
9. First & Last Name*
11. MSHS Referral?

    1. Yes
    2. No
12. MSHS date of intake to program
    MSHS date of intake to program
13. MSHS Anticipated discharge date
    MSHS Anticipated discharge date
15. CBHH Referral

    1. Yes
    2. No
16. CBHH date of intake to program
    CBHH date of intake to program
17. CBHH anticipated discharge date
    CBHH anticipated discharge date
19. First Name*
20. Last Name*
21. Phone Number*
23. Email
25. Address
27. City
28. State
29. Zip Code
33. Client Personal Information
35. First Name*
36. Last Name*
38. Preferred Name
39. Phone Number
41. Email
43. Birth Date
    Birth Date
44. Gender*
    -- Select One --MaleFemaleOtherPrefer not to specify
45. Marital Status*
    -- Select One --Single Married Domestic Partnership Widowed Divorced Separated Unknown
46. Veteran*

    1. Yes
    2. No
    3. Unknown
48. Physical Location

    Where is the client currently staying? i.e. home, assisted living, temporary housing

50. Address
52. City
53. State
54. Zip Code
56. Does client currently reside in a different location than their home?

    1. Yes
    2. No
58. Home Address
60. City
61. State
62. Zip Code
64. Ethnicity
    -- Select One --White Hispanic/Latino Black/African American (non Somalian) Black/African American (Somalian) Native American/American Indian Asian/Pacific Islander Other (please specify)
65. Ethnicity Other

    Please specify

67. Primary Language

    1. English
    2. Spanish
    3. Somali
    4. Other (please specify)
68. Interpreter Required

    1. Yes
    2. No
69. Language Other

    If selected "other" for primary language, please specify

71. Does anyone have legal representation over the client?

    1. Yes
    2. Yes, client is a minor
    3. No
72. Type of legal representation

    1. Guardianship
    2. Health Care Agent
    3. Power of Attorney
    4. Social Security Representative Payee
    5. Other
73. Name
77. Emergency Contact Information

    Person to contact in case of an emergency 

79. Name
80. Relationship to Client
82. Address
84. City
85. State
86. Zipcode
88. Phone Number
89. Email
93. Primary Physician
95. Name
96. Clinic
98. Phone Number
102. Health Insurance Information
104. Health Insurance

     1. Medical Assistance
     2. Medicare
     3. Private
     4. Other
     5. None
     6. Unknown
105. PMI/ID#:
106. Medicare ID#:
107. Private ID#/Name:
109. Other ID#:
111. Income Information

     Assets in the following categories. 

113. Monthly Income
115. Checking
116. Checking
117. Other Assets
121. Reason for making this contact/Specific client needs:*
123. Brief Summary of condition/disabilities/diagnoses:*
124. Help and services the client is currently receiving:*
126. Certified disability*

     Has the client been certified disabled through Social Security or the State Medical Review Team (SMRT)?

     1. Yes
     2. No
     3. Unknown
127. Additional Information
129. Follow up Contact Information
131. Name*
132. Phone Number*
134. Document Upload

     Please attach pertinent documents here or fax to: 218-824-1305 Attn: MnChoice Intake 

Leave This Blank:


136. 1. Receive an email copy of this form.
137. Email address

     This field is not part of the form submission.

138. Submit Submit and Print

* indicates a required field