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Behavioral Health Funds (BHF) Online Eligibility Application

  1. Are you a Crow Wing County Resident?
  2. Do you have a phone number?*
  3. Please bring in a piece of mail with current address. If you are homeless please give your last permanent address with the dates you resided at that address.
  4. Have you had a previous Chemical Health Assessment?
  5. Who referred you for a Chemical Use Assessment or BHF?
  6. Do you have an open case with Child Protection?
  7. Is this assessment for
  8. Are you currently in treatment?
  9. Insurance:
  10. Do you have Medical Assistance (MA) or Minnesota Care?
  11. Do you have private insurance or a PMAP, HMO coverage (Medica, Health Partners, ect.)?
    (please fill out the information below)
  12. Please provide a copy of the card.
  13. Household Size
  14. Marital Status:*
  15. Income
    (Please provide the two most recent proofs of income at the time of assessment.)
  16. Do you and/or your spouse receive earned income?*
    Include employment, tips, commission, other, etc.
  17. Per
  18. Are you and/or your spouse on any assistance programs?*
    General Assistance (GA), Social Security (SSI, RSDI)
  19. Do you recieve child support or any other income? *
    Inheritance, unemployment, royalties, investment dividends, etc
  20. Per
  21. Do you pay any child support?*
  22. Per
  23. Per
  24. How would you like to receive notice of your eligibility for a Chemical Use Assessment?

    (By selecting and providing us with the contact information below, you are authorizing us to contact you with private information via any of the ways you have authorized.)

  25. By submitting this form, I certify this information to be accurate to the best of my knowledge and ability.
    You will be asked to sign a copy of this form at the time of your assessment.
  26. Crow Wing County reserves the right to terminate treatment immediately if any of the above information is found to be fraudulent.
    Crow Wing County does not discriminate on the basis of race, color, national origin, sex, religion, age and handicapped status in employment or the provision of services.
  27. By submitting your email address you agree to communicate with Crow Wing County via e-mail.
  28. Office Use Only
  29. Verifications:
  30. Eligibility Determination:
  31. Crow Wing County does not discriminate on the basis of race, color, national origin, sex, religion, age and handicapped status in employment or the provision of services.
  32. Leave This Blank:

  33. This field is not part of the form submission.