Revised 3.10.2020
MnC
HOICES Assessment Referral Form
Please complete referral form, save, and send as an attachment to Long Term Services and Supports
Intake at: RS-SS-LTSS-Intake@co.anoka.mn.us or via fax at: (763) 324-1043. Questions - call (763) 324-1450
Date
Referral Source Name
Phone
Referral Source Relationship to the Client
Client Information
Name
Date of Birth
Sex Male Female
Social Security Number
Marital Status Single/Never Married Married Widowed Divorced Unknown
Physical Location Address
City State
ZIP
Mailing Address (if different)
City State
ZIP
Phone Number
County of Financial Responsibility
Email Address
Preference to be contacted
Language Spoken
Interpreter Needed Yes No
Certified Disabled
Yes No If yes Social Security or State Medical Review Team (SMRT)
Program Interest AC ECS EW CADI CAC BI DD PCA CSP Only
Services currently receiving and notes
With others, if with others Spouse Parents Young Children Adult Children
Alone Assisted Living Nursing Facility Other