Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

MnChoice Assessment Intake Form

  1. Referral Source Information

  2. Referral Source/Person completing form*

  3. Is client aware of the referral?

  4. Client Personal Information

  5. Veteran*

  6. Physical Location

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

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

  8. Please specify

  9. Primary Language

  10. Interpreter Required:

  11. If selected "other" for primary language, please specify

  12. Does anyone have legal representation over the client?

  13. Type of legal representation

  14. Emergency Contact Information

    Person to contact in case of an emergency

  15. Primary Physician

  16. Health Insurance Information

  17. Health Insurance

  18. Income Information

    Assets in the following categories.

  19. Certified disability*

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

  20. Follow up Contact Information

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

  22. Leave This Blank:

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