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
PMI
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 Interested in
Services currently receiving and notes
Current Living Situation
With others, if with others Spouse Parents Young Children Adult Children
Alone Assisted Living Nursing Facility Other
Revised 3.10.2020
Legal Authority
Does the person have someone who signs documents or helps make decisions about health care, money or other
issues? No Yes, if yes,
Informal Decision-making Support Responsible Party Power of Attorney (POA) Guardian
Parent. If minor child, need parent’s Name Date of Birth
Name
Relationship to Client
Address
City
State
ZIP
Phone
Email
Emergency Contact
Name
Relationship to Client
Address
City
State
ZIP
Phone
Email:
Contact for Scheduling
Name
Relationship to Client
Address
City
State
ZIP
Phone
Email
Insurance and Financial Status
Insurance
Medical Assistance
On Medical Assistance Needs to Apply for Medical Assistance
Has Application and needs to complete and return Has Applied for Medical Assistance, result pending.
Private Insurance
Policy Number
Effective Date
Medicare A, B, D
Policy Number:
Effective Date
Veteran Status Yes No Unknown
Veterans Benefits Yes No Unknown
Financial Status
If Married
Liquid assets less than or equal to $50,000 Liquid assets greater than $50,000 Unknown
If Single
Liquid assets less than or equal to $25,000 Liquid assets greater than $25,000 Unknown
Revised 3.10.2020
Providers
Primary Physician Name
Phone Number
Mental Health Provider
Phone Number
Home Care Agency
Phone Number
Specialty Clinic
Phone Number
Other Provider
Phone Number
Diagnosis
1
2
3
4
Assistance needed in the following areas
Sitting up/moving around in bed
Walking
Oxygen Therapy
Getting in/out of bed/chair
Bathing
Physical Therapy
Grooming (combing hair, brushing teeth, shaving)
Eating
Occupational Therapy
Toileting: any incontinence? Yes No
Tube Feedings
Speech Therapy
Dressing
Injections
IV Therapy
Other
Wound Care
Medication Compliance
Other
Referral Reason
Caregiver Need Supports requested Permanent Loss Inability of caregiver / Temporary Loss
Comments
Falls Supervision Harmful behaviors
Safety Concerns
Comments
Behavioral or Emotional Concerns Yes No
Comments
Concerns regarding a child’s communication, learning or social skills Yes No
Comments
Memory Concerns Yes No
Comments
Housing/Living Arrangements Concerns
Services and Supports Current services not adequate Education/school/transition Modifications
Specialized equipment and supplies
Comments
Other Concerns
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