MnCHOICES Referral Form

Contact us

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

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.