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					                                                                                                             Community Services

                                                                                                             WCCS-74000-77 (12-15-09)



                                                                                                                 Authorization #



                                                      Chemical Health Services
                                          Rule 25 Assessment Application

                       Name:
                                                         (last, first, middle initial)

                       DOB:                                                     SS #:

     WASHINGTON COUNTY RESIDENT: Yes                        No
     If yes, bring residency verification. (Anything with your name and address such as an electric bill, credit card bill,
     or a letter signed by you or who you live with to verify how long you have lived at your current address.)
                       Address:


                   Please provide verification of your address. (Example: A copy of a lease or recent utility bill
                       with your name on it, or a copy of mail from the homeowner you are living with or
                             a signed statement from the homeowner that you currently live with.)

     Phone #:                                                              Cell #:
     Gender: M               F
     Race:          ____ 1 - White 2 - Black 4 - American Indian 5 - Asian/Pacific Islander 8 - Other 9 - Unknown
     Non-Reservation American Indian: Yes                  No
     Hispanic: Yes           No
     Marital Status (check one): Married                 Separated              Single        Widowed              Divorced
     DWI: Yes           No
     COURT ORDERED: Yes                 No                 What County:
     What was the charge:
     Probation Officer:                                              Probation Officer’s Phone #:

     Medical Assistance (MA), General Assistance Medical Care (GAMC), or Minnesota Care: Yes                                       No
                           (If checked yes, MA #:                               )


 Service Center Cottage Grove         Service Center Forest Lake                  Government Center             Service Center Woodbury
    13000 Ravine Parkway                 19955 Forest Road N                   14949 62nd St N P.O. Box 30              2150 Radio Drive
   Cottage Grove, MN 55016              Forest Lake, MN 55025                   Stillwater, MN 55082-0030            Woodbury, MN 55125
    Phone: 651-430-4159                  Phone: 651-275-7260                      Phone: 651-430-6455                Phone: 651-275-8650
      Fax: 651-430-4157                   Fax: 651-275-7263                          Fax: 651-430-6605                Fax: 651-275-8682
      TTY: 651-430-4119                   TTY: 651-275-7264                         TTY: 651-430-6524                 TTY: 651-275-8653

                                                         www.co.washington.mn.us
                                     Washington County is an equal opportunity organization and employer
                                                                                                    WCCS-74000-77 (12-15-09)


                                                Chemical Health Services

PRIVATE INSURANCE or HMO Coverage: Yes                     No
(If yes, please complete the following or send a copy of your insurance card.)
Insurance Company Name:
Insurance Company Address:
Employer Name:
Employer Address:
Policy Name/Number:                                             Group Name/Number:
Contact Person/Phone Number:
Coverage Type:
Any Limitation/Co-Pay:

EMPLOYED: Yes        No    What does count as income is listed below, please fill in amounts as
specified and attach documentation of recent payment. (Based on current month’s income.)
$               Cash for Wages or Salary                               $              Veterans Benefits
    (Please attach last two pay stubs)                                 $              Child Support (received)
$               GA, SSI Disability                                     $              Military Family Allotments
$               Social Security                                        $              Private or Government
Pensions
$               Railroad Retirement                                    $              Insurance
$               Unemployment Compensation                              $              Annuities
$               Royalties                                              $              Interest
$               Rental received from rental owned properties

HOUSEHOLD SIZE:
INCOME:                                   (Total based on above check list)
Minus       −                             (Court Ordered Child Support Payment - Include Verification)
TOTAL INCOME: $

Client Signature

                        (Washington County reserves the right to terminate treatment immediately
                                if any of the above information is found to be fraudulent.)

                                          Phone: 651-430-6561  Fax: 651-430-6639
                                         ChemicalHealthServices@co.washington.mn.us