Our Services
Home and Community Based Services
Adult Rehabilitative Mental Health Services
Targeted Case Management Services (TCM)
Integrated Community Support (ICS)
Housing Support (Formerly: GRH)
Housing Stabilization Service
Adult Day Services
Home-delivered meals
Referral
+1 (320) 774-1061
info@credentcare.com
2719 W Division St STE 9, St. Cloud, MN 56301
Referral
Home
About Us
Our Services
Adult Day Services
Home and Community Based Services
Basic Support Services
Intensive Support Services
Adult Rehabilitative Mental Health Services
Housing Stabilization Service
Targeted Case Management Services (TCM)
Home-delivered meals
Housing Support (Formerly: GRH)
Integrated Community Support (ICS)
Counseling & Therapy
Children’s Therapeutic Services & Supports (CTSS)
Coordinated Entry (CE) – (CoC)
MNsure Applications
Careers
Contact Us
patient intake
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patient intake
Patient Intake Form (#3)
Newsletter
RECIPIENT INTAKE
Date of Admission/Intake
Source of Referral (Name)
Source of Referral (Address)
Address Line 1
City
State
Zip Code
Phone
Email
Client Information
First Name
Middle Name
Last Name
Address
Address
City
State
Zip Code
Phone
Email
Social Security
Birth date
Age
Gender
Male
Female
Employment Status
Full-time
Part-time
Unemployed
Other
Living Arrangement
Lives alone
Lives with spouse
Lives with family
Other
Ethnicity
Black/African American
African
White or Caucasian
Asian
Hispanic/Latino
Other
Marital Status
Single
Married
Divorce
Widowed
Other
Emergency Contact Information
Name
Phone/Mobile
Email
Family, Friends or other supports (if applicable) for coordination
Name
Relationship
Phone/Mobile
Is there a gender preference regarding the assigned staff?
Yes
No
Submit
