MnCHOICES Referral Form

The MnCHOICES assessment allows for anyone of any age with a disability to access the support services needed to stay in their homes. MnCHOICES helps make decisions about long-term services that help individuals thrive in their communities. Fill out the form below to refer a client, family member, friend or yourself for a MnCHOICES assessment.

After submitting the form, a MnCHOICES social worker will be in contact within two business days to discuss eligibility or set up an assessment.

1 Start 2 Complete

* Indicates a required field

Your name: *

Your email address:

Your phone number: *

Do you need an interpreter?

Yes

Are you: *

An agency provider

A family member or friend

Looking for assistance for yourself

What agency do you work for?

What (if any) is the discharge date for the client?

Month

Day

Year

The name of the person who needs services: *

The name of the person you're referring: *

The client's date of birth: (optional)

Month

Day

Year

The person's date of birth: (optional)

Month

Day

Year

Your date of birth: (optional)

Month

Day

Year

Do you have Medical Assistance? *

Yes

Does the client have Medical Assistance? *

Yes

Unknown

Does the person you're referring have Medical Assistance? *

Yes

Unknown

What (if any) services and support do you already have?

What (if any) services and support does the client you're referring already have?

What (if any) services and support does the person you're referring already have?

Other services requested:

Who should be contacted?

List the name of the person who should be contacted by MnCHOICES Intake staff. (If different than above.)

Their phone number *

Leave this field blank

Privacy Notice
The information you provide to us will be classified as private data on individuals and will be used to determine whether you meet the legal requirements for the services you are requesting. Providing the information we request from you is voluntary. Refusing to provide the information we request from you may prevent us from determining your eligibility for services. The private information you provide to us may also be shared with care coordinators, care providers, and/or case managers if applicable as authorized by law.

Determine your eligibility for senior and disability services

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MnCHOICES Referral Form

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Determine your eligibility for senior and disability services