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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.