ADMISSION FORM

The adult community-based residential correctional facility referral form on each client to be admitted into residency includes at a minimum: A. name; B. address; C. date of birth; D. sex; E. reason for referral; F. whom to notify in case of emergency; G. date information gathered; H. signature of both interviewee and interviewer gathering information; I. name of referring agency of committing authority; J. special medical problems or needs; K. legal status, including jurisdiction, length, and conditions of placement; L. financial arrangements for medical care; M. financial arrangements for placement; N. present medications; O. driver's license or Minnesota state identification number; and P. vehicle title and vehicle insurance, if applicable.