2. Date of Request*
   Date of Request
4. First Name:*
5. Last Name*
6. Date of Birth:*
7. Social Security No.
9. Are you a Crow Wing County Resident?

   1. Yes
   2. No
10. If no, which county do you reside in?
11. If you do not know your county, click here:
    USPS Zip Code Lookup

    Type your address into the fields and press submit. Click on "Show Mailing Industry Details."
13. Address:*
14. City*
16. Do you have a phone number?*

    1. Yes
    2. No
17. Phone:
19. Please bring in a piece of mail with current address. If you are homeless please give your last permanent address with the dates you resided at that address.
23. Have you had a previous Chemical Health Assessment?

    1. Yes

    1. No
24. If yes, date:
25. Place:
27. Who referred you for a Chemical Use Assessment or BHF?

    1. Self
    2. Corrections

    1. Court

    1. Other
28. Other:
30. Do you have an open case with Child Protection?

    1. Yes

    1. No
31. If yes who?
33. Social Worker:
34. County:
36. Probation Officer:
37. Current Charges:
38. Next Court Date:
40. Is this assessment for

    1. Alcohol Use or

    1. Other Drug Use
41. Other:
43. Are you currently in treatment?

    1. Yes

    1. No
47. Insurance:
49. Do you have Medical Assistance (MA) or Minnesota Care?

    1. Yes

    1. No
51. If yes PMI#:
52. County:
54. Do you have private insurance or a PMAP, HMO coverage (Medica, Health Partners, ect.)?

    1. Yes

    1. No

    (please fill out the information below)
56. Insurance Company Name:
57. Insurance Company Phone Number:
59. Policy Holder's Name:
60. ID and Group Number
62. Please provide a copy of the card.
66. Household Size
69. Marital Status:*

    1. Single
    2. Married

    1. Separated
    2. Divorced

    1. Widowed
71. Who do you live with? (e.g. parents, spouse, biological children; please do not include unmarried partners or their children.)
75. Income
    (Please provide the two most recent proofs of income at the time of assessment.)
77. Do you and/or your spouse receive earned income?*

    1. Yes

    1. No

    Include employment, tips, commission, other, etc.
78. Amount:
79. Per

    1. Week
    2. Two Weeks
    3. Month
    4. Year
81. Are you and/or your spouse on any assistance programs?*

    1. Yes

    1. No

    General Assistance (GA), Social Security (SSI, RSDI)
82. Amount per month:
84. Do you recieve child support or any other income? *

    1. Yes

    1. No

    Inheritance, unemployment, royalties, investment dividends, etc
85. Amount:
86. Per

    1. Week
    2. Two Weeks
    3. Month
    4. Year
88. Do you pay any child support?*

    1. Yes

    1. No
89. Amount:
90. Per

    1. Week
    2. Two Weeks
    3. Month
    4. Year
92. Total income, less child support paid:
93. Per

    1. Week
    2. Two Weeks
    3. Month
    4. Year
95. How would you like to receive notice of your eligibility for a Chemical Use Assessment?

    (By selecting and providing us with the contact information below, you are authorizing us to contact you with private information via any of the ways you have authorized.)

97. Select one below:
    -- Select One --PhoneE-mailMailNotify Contracted Treatment Provider
99. Phone #
100. E-mail address
102. Address
104. Contracted Treatment Provider Fax # or E-mail address
108. By submitting this form, I certify this information to be accurate to the best of my knowledge and ability.
     You will be asked to sign a copy of this form at the time of your assessment.
110. Crow Wing County reserves the right to terminate treatment immediately if any of the above information is found to be fraudulent.
     Crow Wing County does not discriminate on the basis of race, color, national origin, sex, religion, age and handicapped status in employment or the provision of services.
112. Please enter your email address, if you would like a return reciept
     By submitting your email address you agree to communicate with Crow Wing County via e-mail.
116. Office Use Only
118. Date
119. Time
121. Verifications:

     1. Photo ID

     1. Proof of Address

     1. Proof of Income
123. Eligibility Determination:

     1. Eligible
     2. Not Eligible
124. Authorization # if Eligible
126. Crow Wing County does not discriminate on the basis of race, color, national origin, sex, religion, age and handicapped status in employment or the provision of services.
Leave This Blank:


128. 1. Receive an email copy of this form.
129. Email address

     This field is not part of the form submission.

130. Submit

* indicates a required field