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HSS Self Referral Form
* Indicates required question
Email
*
Record my email address with my response
Legal Name
*
Your answer
Are you on Medical Assistance?
*
Yes
No
Medical Assistance Number (8 digit PMI or Medicaid number Located on insurance card)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email
Your answer
Your Preferred Method of Contact
Choose
Phone Call
Text
Email
Do you have a County Case Manager?
*
Choose
Yes
No
Maybe
Which County?
Choose
Anoka
Sherburne
Sterns
Wright
Are you currently living in your car or a place not meant for housing?
Yes
No
Clear selection
Which city are you currently living/staying in?
Your answer
Which city would you like to live in?
Your answer
Do you have a Medical Professional you are currently seeing?
Yes
No
Clear selection
How did you hear about us?
Choose
Internet
Friend
County Worker
Food Shelf
Other
Briefly describe your current living situation:
*
Your answer
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