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
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Client Application
Demographics
First Name:
Middle Name:
Last Name:
Preferred Name:
Maiden Name:
Gender:
-- Select Prefix --
Female
Male
Non-Binary
Undetermined
DOB:
SSN:
County of Residence:
-- Select County --
Adair County | County
Adams County | County
Allamakee County | County
Appanoose County | County
Audubon County | County
Benton County | County
Black Hawk County | County
Boone County | County
Bremer County | County
Buchanan County | County
Buena Vista County | County
Butler County | County
Calhoun County | County
Carroll County | County
Cass County | County
Cedar County | County
Cerro Gordo County | County
Cherokee County | County
Chickasaw County | County
Clarke County | County
Clay County | County
Clayton County | County
Clinton County | County
Crawford County | County
Dallas County | County
Davis County | County
Decatur County | County
Delaware County | County
Des Moines County | County
Dickinson County | County
Dubuque County | County
Emmet County | County
Fayette County | County
Floyd County | County
Franklin County | County
Fremont County | County
Greene County | County
Grundy County | County
Guthrie County | County
Hamilton County | County
Hancock County | County
Hardin County | County
Harrison County | County
Henry County | County
Howard County | County
Humboldt County | County
Ida County | County
Iowa County | County
Jackson County | County
Jasper County | County
Jefferson County | County
Johnson County | County
Jones County | County
Keokuk County | County
Kossuth County | County
Lee County | County
Linn County | County
Louisa County | County
Lucas County | County
Lyon County | County
Madison County | County
Mahaska County | County
Marion County | County
Marshall County | County
Mills County | County
Mitchell County | County
Monona County | County
Monroe County | County
Montgomery County | County
Muscatine County | County
O'Brien County | County
Osceola County | County
Page County | County
Palo Alto County | County
Plymouth County | County
Pocahontas County | County
Polk County | County
Pottawattamie County | County
Poweshiek County | County
Ringgold County | County
Sac County | County
Scott County | County
Shelby County | County
Sioux County | County
Story County | County
Tama County | County
Taylor County | County
Union County | County
Van Buren County | County
Wapello County | County
Warren County | County
Washington County | County
Wayne County | County
Webster County | County
Winnebago County | County
Winneshiek County | County
Woodbury County | County
Worth County | County
Wright County | County
Email Address:
Home Phone:
Cell Phone:
Marital Status:
-- Select Marital Status --
Divorced
Married (Includes Common law)
Separated
Single
Widowed
Race:
-- Select Race --
American Indian or Alaska Native
Asian or Pacific Islander
Black or African American
Other (biracial; Sudanese; etc.)
Unknown
White
Primary Language:
-- Select Language --
Bosnian
Croatian
English
Filipino
French
German
Other
Serbo-Croatian
Sign language
Spanish
Turkish
Vietnamese
Military Branch Status:
-- Select Military Branch --
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Unknown
WAAC/WAC
Military Discharge Date:
Military Discharge Type:
-- Select Military Discharge Type --
Bad Conduct (BCD)
Dishonorable
Entry Level Separation (ELS)
General
Honorable
Medical
Other Than Honorable (OTH)
US Citizen:
Legal Status:
-- Select Legal Status --
Involuntary, civil commitment
Involuntary, criminal commitment
Voluntary
Primary Insurance Type:
-- Select Primary Insurance Type --
Consumer Pays
HAWK-I
Iowa Health & Wellness
Iowa Health & Wellness – Med Exempt
Medicaid
Medically Needy
Medicare
Not Insured
Private Third Party
Managed Care Organization:
-- Select Primary Care Organization --
IME
Iowa Total Care
Molina Healthcare of Iowa
TBD/Unknown
Wellpoint Iowa, Inc
Company Name:
Primary Policy #:
Primary Premium:
Primary Spend Down:
Primary Start Date:
Secondary Insurance Type:
-- Select Secondary Insurance Type --
Consumer Pays
HAWK-I
Iowa Health & Wellness
Iowa Health & Wellness – Med Exempt
Medicaid
Medically Needy
Medicare
Not Insured
Private Third Party
Managed Care Organization:
-- Select Secondary Care Organization --
IME
Iowa Total Care
Molina Healthcare of Iowa
TBD/Unknown
Wellpoint Iowa, Inc
Secondary Company Name:
Secondary Policy #:
Secondary Premium:
Secondary Spend Down:
Secondary Start Date:
Address
Current Address:
Address Begin Date:
City:
State:
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Residential Arrangement:
-- Residential Arrangement --
24-hour Habilitation
24-hour Supported Community Living
College
Correctional facility
Corrections Halfway House
Duplicate/error
Foster care/Family Life home
Homeless/Shelter/Street
ICF/ID
ICF/Nursing Home
ICF/PMI
Other
Other
Private residence/household- Alone
Private residence/household- w/ Relatives
Private residence/household- w/ Unrelated persons
RCF/ID
RCF/PMI
Residential Care Facility
State MHI
State Resource Center
# of Roommates:
Previous Address:
Previous Start Date:
Previous End Date:
Previous City:
Previous State:
-- Select Previous State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Previous Zip Code:
Employment & Education
Current Employment Status:
-- Select Employment Status --
Employed, full-time
Employed, part-time
Homemaker
In the Armed Forces
Other/Not applicable
Retired
Seasonally employed
Self-Employed
Sheltered work employment
Student
Supported employment
Unemployed, available
Unemployed, unavailable for work
Voc-Rehab
Volunteer
Work activity employment
Current Employer Name:
Current Employer City:
Current Employer State:
-- Select Employment State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employer Start Date:
Hourly Wage:
Hours Worked Weekly:
Current Employer #2 Name:
Current Employer City:
Current Employer State:
-- Select Employment State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employer State Date:
Hourly Wage:
Hours Worked Weekly:
Education Level:
-- Select Education Level --
Associates
Bachelors
Certificate
Community Work Experience
Current Student
Doctorate
GED/HiSET
H.S. Diploma
IEP Mgt Exempt
Masters
None
Post Secondary
School Related Meeting
Skills Training Program
Special Education
Years of Education:
Interested Parties
Emergency Contact First Name:
Emergency Contact Last Name:
Emergency Contact Relationship:
-- Select Relationship --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
Contact Address:
Emergency Contact Phone:
Legal Represenative:
-- Select Legal Rep Type --
Conservator
Legal Representative
Protective Payee
Legal Rep First Name:
Legal Rep Last Name:
Legal Rep Address:
Legal Rep Phone:
Has Financial Decision Maker:
Financial Decision Maker First Name:
Financial Decision Maker Last Name:
Financial Decision Maker Address:
Financial Decision Maker Phone:
In Household First Name:
In Household Last Name:
Relationship:
-- Select Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
In Household DOB:
In Household #2 First Name:
In Household #2 Last Name:
#2 Relationship:
-- Select Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
#2 DOB:
In Household #3 First Name:
In Household #3 Last Name:
#3 Relationship:
-- Select Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
#3 DOB:
In Household #4 First Name:
In Household #4 Last Name:
#4 Relationship:
-- Select Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
#4 DOB:
In Household #5 First Name:
In Household #5 Last Name:
#5 Relationship:
-- Select Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
#5 DOB:
Current Caseworker/Social Worker
Please search CSN Users for your care worker if no care worker then search by agency
Search Users:
Search Agency:
Income & Resources
Income: Please use whole dollar amount!
Child Support
Employment Wages
Family & Friends
FIP
Food Stamps
General Assistance
Pension
Private Relief Agency
Public Assistance Payments
R/R Pension
Social Security
SSDI
SSI
VA Benefits
Workers Comp
Other
Household Resources: Please use whole dollar amount!
Burial plots
Cash on hand
CD's
Checking
Dividend interest
Saving
Stocks/Bonds
Trust funds
Other
Disability Group/Primary Diagnosis
Disability Group:
-- Select Disability Group --
00 - Physical/Health Disability
14 - Assistance to District Court System
15 - Court Proceedings
16 - Juvenile Justice Administration
30 - Public Health Services
31 - General Assistance
32 - Veterans Affairs
33 - Juvenile Services
34 - Elderly Services
35 - Substance Abuse
40 - Mental Illness
42 - Intellectual Disabilities
43 - Other Developmental Disabilities
44 - MH/DD General Administration
45 - County Provided Case Management
46 - County Provided Services
47 - Brain Injury
91 - General Services
Diagnosis Determined by:
Elgibility Info
App Referral Source:
-- Select App Referral Source --
Community Corrections
Family and/or friend(s)
Hospital
Other
Other Case Management
Physician
RCF/ICF
Self
Social service agency other than case management
Targeted Case Management
Application Start Date:
Application Status:
-- Select Application Status --
Approved
Closed
Denied
Pending
Provisional
Reviewing
Submitted
Reason for Services:
Assessment
Assistive Technology
Case/Service Management
Comp. Family Support
Education
Employment
Financial Support
Health Care
Housing
Information about Rights
Information on Training
In-Home Services
Mental Health Services
Other
Personal Assist. Services
Recreation
Skill Development
Transportation
(Hold the CTRL key down to select multiple reasons.)
Additional Information(i.e.Provider Name, Contact Information, Specific Service, etc.):
App Denial Reasons:
Applicant discontinued services
Applicant failed to return required information
Client moved out of state
Client not a legal U.S.CItizen
Does not meet county plan criteria
Does not meet diagnostic group criteria-alzheimer
Does not meet diagnostic group criteria-other
Does not meet diagnostic group criteria-substance
Does not meet service plan criteria
Doesn't meet diagnostic group criteria-brain injury
Over Income Guidelines
Over Resources Guidelines
(Hold the CTRL key down to select denial reasons.)
Signature of Applicant
If completed by someone other than the potiential client please type name here (who are you, contact info, etc):
Other Applicant Relationship:
-- Select Other Applicant Relationship Type --
Child
Foster Parent
Friend
Grandparent
Other
Parent
Parent (Non-Custodial)
Professional
Roommate
Sibling
Significant Other
Spouse
Client Signature:
Submit Client Application