form03

Name

First MI Last

DOB

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Marital Status

Never

Married living with spouse

Single

Legally Seperated

Divorced

Widowed

Hispanic Heritage

Yes

Race

Ameriucan Indian/Alaskan Native

Asian

Black or African American

Pacific Island/Native Hawaiian

White

Social Security Number

Other Household Members

Name

First Last

Date of Birth

Relationship

Name

First Last

Date of Birth

Relationship

Name

First Last

Date of Birth

Relationship

Name

First Last

Date of Birth

Relationship

Financial Information

Do you receive assistance from:

Diversionary Work Program(DWP / MN Family Investment Project (MFIP)

Yes

Are you an adult caretaker of children who receive DWP/MFIP

Yes

Do you receive Supplemental Security Income (SSI)?

Yes

If Yes

Aged

Blind

Disabled

Do you receive Minnesota Supplemental Aide (MSA)?

Yes

Do you receive Medical Assistance (MA)?

Yes

Complete the information below for all family members (including yourself) who are age 14 or older.

Complete the information below for all family members (including yourself) who are age 14 or older. Use + to add people

Kind of Income (Monthly Gross Amount)

Wage or Salary

NET Income from Self Employment

NET Farm Income

Social Security

Dividends – Interest – Rentals – Royalties

General Assistance

Pensions and Annuities

Unemployment Compensation

Workers Compensation

Alimony

Child Support

Veterans Pensions

Do you have private insurance

Yes

Insurance Waiver Appeal: Please state reason the waiver should be granted on form

Insurance Waiver Appeal: You may request that your application for the Mental Health Client Assistance Program be considered if you feel there are special and unusual circumstances. Special or unusual circumstances could include mental health services not being a covered service with your current insurance or the inability to pay large deductibles or copays. The appeal must be in writing stating the reasons the waiver should be granted and desire for review. The Mental Health Supervisor, in consultation with the Director, will review requests and determine if waiver will be granted. If the waiver is granted, the Mental Health Client Assistance Program fee schedule will be utilized to assess any potential fees.

My signature below authorizes the exchange of information between Southern Minnesota Behavioral Health and Brown County Human Services to include

All information provided on this application
• Copies of proof of income reported. • Diagnostic information including mental health professional recommendations • Service dates and services provided

I understand this information is needed in order to process my application for the Client Assistance Program and will not be used for any other purpose other than eligibility determination for the Client Assistance Program. I understand the request for Mental Health Client Assistance Program funding and I agree with this request for assistance. I understand that the consent will automatically expire one year from the date of my signature. I understand that I may revoke this consent at any time upon written notice (not retroactive) and if I revoke my consent to share information with Brown County Human services my eligibility for the Mental Health Client Assistance Program will also be revoked.

Client/Legal Guardian Signature

First Last

Date

CAPTCHA

APPLICATION FOR MENTAL HEALTH CLIENT ASSISTANCE PROGRAM

Other Household Members

Financial Information

Do you receive assistance from:

Complete the information below for all family members (including yourself) who are age 14 or older.

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