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MnChoice Assessment Intake Form

2. Referral Source Information

4. Referral Source/Person completing form*

   1. Client
   2. Benton 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*

10. Phone Number*

11. Email

13. Address

15. City

16. State

17. Zip Code

21. Client Personal Information

23. First Name*

24. Last Name*

25. Phone Number

27. Preferred Name

29. Birth Date
    Birth Date

30. Gender*
    -- Select One --MaleFemaleOtherPrefer not to specify

31. Marital Status*
    -- Select One --SingleMarriedDomestic PartnershipWidowedDivorcedSeparatedUnknown

32. Veteran*

    1. Yes
    2. No
    3. Unknown

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

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

36. Address

38. City

39. State

40. Zip Code

42. Does client currently reside in a different location than their home?

    1. Yes
    2. No

44. Home Address

46. City

47. State

48. Zip Code

50. Ethnicity
    -- Select One --WhiteHispanic/LatinoBlack/African American (non Somalian)Black/African American (Somalian)Native American/American IndianAsian/Pacific IslanderOther (please specify)

51. Other

    Please specify

52. Native Tribe

54. Primary Language

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

55. Interpreter Required:

    1. Yes
    2. No

56. Other Language

    If selected "other" for primary language, please specify

58. Does anyone have legal representation over the client?

    1. Yes
    2. Yes, client is a minor
    3. No

59. Type of legal representation

    1. Guardianship
    2. Health Care Agent
    3. Power of Attorney
    4. Social Security Representative Payee
    5. Other

61. Guardian Name

62. Guardian Phone Number

66. Emergency Contact Information
    Person to contact in case of an emergency

    Person to contact in case of an emergency

68. Name

69. Relationship to Client

71. Address

73. City

74. State

75. Zip Code

77. Phone Number

78. Alternate Phone Number

82. Primary Physician

84. Name

85. Clinic

87. Phone Number

91. Health Insurance Information

93. Health Insurance

    1. Medical Assistance
    2. Medicare
    3. Private
    4. Other
    5. None
    6. Unknown

94. PMI/ID #:

95. Medicare ID #:

96. Private ID#/Name:

98. Other ID#/Name:

100. Financial Worker's Name:

102. Income Information
     Assets in the following categories.

     Assets in the following categories.

104. Monthly Income

105. Spouse's Monthly Income

107. Checking

108. Savings

109. Other Assets

113. Reason for making this contact/Specific client needs:*

115. Brief Summary of condition/disabilities/diagnoses:*

116. Help and services the client is currently receiving:*

118. Certified disability*

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

     1. Yes
     2. No
     3. Unknown
119. Additional Information

121. Follow up Contact Information

123. Name*

124. Phone Number*

126. Document Upload

     Please attach pertinent documents here or fax to: 320-968-5330 Attn: MnChoice Intake

128. Additional Documents

130. Additional Documents

Leave This Blank:


132. 1. Receive an email copy of this form.
133. Email address

     This field is not part of the form submission.

134. Submit

* indicates a required field