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Martin County Center: (507) 238-4757
Faribault County Center: (507) 526-3265
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Martin County Center: (507) 238-4757
Faribault County Center: (507) 526-3265

Home   |   Contact   |  Calendar  |   Blog

Intake & Referral Form to Human Services of Faribault & Martin Counties

CLIENT INFORMATION:

Last Name:
First:
MI:
DOB:*
Address:
City:
State:
Zip:
Phone:
Cell:
E-Mail:
Language:
English
Spanish
Other:

IF YOU WOULD LIKE TO MAKE A CHILD PROTECTION REPORT, PLEASE CALL OUR OFFICE IMMEDIATELY AT 507-238-4757. 


IF YOU WOULD LIKE TO MAKE AN ADULT PROTECTION REPORT, PLEASE CALL THE MINNESOTA ADULT ABUSE REPORTING CENTER AT 844-880-1574.

I would like information about (check all that apply):
Alcohol & Drug Abuse (Chemical Dependency Assessment)
Child Support
Day Care/Foster Care Licensing
Developmental Disabilities Services
Pregnancy, new baby information or parenting information
(WIC) Women, Infant, & Children Nutritional Program
Healthy Families Home Visiting
Baby Café / Breastfeeding Support
Immunizations/Child Health Care Screening
Mental Health/Help Arranging Counseling
Financial Assistance (cash, daycare, food support, medical assistance, etc.)
Parent Support Outreach Program
Screening for In-Home Services, Assisted Living or Nursing Home
REFERRING AGENCY: (If not self-referral) 
Referred by: 
Date:
Relationship to Client
Organization (if applicable)
Phone
Fax
Reason for Referral
Additional documentation being sent
Yes
No
Has client consented to AND is aware of the referral?
Yes
No

*Client must consent to referral for our agency to respond to this referral. 

Submit

Martin County Center

115 West 1st Street
Fairmont, Minnesota 56031

Telephone: (507) 238-4757

Fax: (507) 238-1574

Faribault County Center

412 North Nicollet
PO Box 217
Blue Earth, Minnesota 56013

Fax: (507) 526-2039

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