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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
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
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.
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