Minnesota Administrative Rules

2920.4400 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.

Statutory Authority:

MS s 241.021

History:

9 SR 1655; 36 SR 635

Published Electronically:

January 3, 2012