MHDS Client Application Instructions:
  • Please fill out as much of the Client Application as possible.
  • Red labels are required information and black labels are not required information to submit application.
  • Please sign at the bottom before submitting using your mouse or finger on screen if touch screen.
Client Application
Demographics







Address





Employment & Education



Interested Parties
Current Caseworker/Social Worker
Please search CSN Users for your care worker if no care worker then search by agency
Income & Resources
Income: Please use whole dollar amount!
Household Resources: Please use whole dollar amount!
Disability Group/Primary Diagnosis
Elgibility Info
(Hold the CTRL key down to select multiple reasons.)
(Hold the CTRL key down to select denial reasons.)
Signature of Applicant
^^ Sign above using mouse or touch screen if applicable ^^

Undo