Form Center

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Administrative Services

  1. Data Request Form - Members of the Public

    Members of the Public should utilize this form to request data

County Board

  1. Citizen eInput

    This form is used to submit Citizen Input to the County Board.

  1. Itasca County Committee/Commission/Board Application

    This form is used to apply for positions on Itasca County Committees/Commissions/Boards.

Health & Human Services

  1. Adult Health Intake

    Public health intake form.

  2. Application for MLRTC Flex Funds

    Form for case managers to fill out to request flex funds for a client

  3. Health Care Transportation Reimbursement Form

    Medical provider only completes this reimbursement form.

  4. Itasca County AMH Case Management Closure Form

    Form used to close case management services.

  5. Itasca County CMH Case Management Closure Form

    Form used to close case management services.

  6. Itasca County Health and Human Services Housing Support Program Provider Application

    online application for Housing support

  7. Medicare Redetermination Request Form
  8. MN DHS Housing Support Vendor Profile Form

    vendor profile name

  9. MN DHS: SFY 2023 Housing Support Agreement - Group Settings

    DHS Housing support agreement

  10. Online: Children's mental health Respite Grant Application

    Online application for case managers to request respite

  11. Online: Adult Mental Helath Case Management Client Review

    Review form that can be filled out by the case manager to update the county on how the client is doing

  12. Online: Children's Mental Health Case Managment Referral Form

    Online form to submit referrals for children's mental health case management services.

  13. Parent Support Outreach Program (PSOP)

    online referral form for the Parent Support Outreach Program

  1. Application for Appointment

    Please fill out an application for an appointment with the Itasca County Health and Human Services Advisory Committee.

  2. Habitability Inspection Form Group Residential Housing – Supportive Housing Setting

    Group Residential Housing (GRH) supportive housing settings must have an approved habitability inspection. The habitability inspection... More…

  3. Housing Support Billing Form

    form used for Housing Support billing (GRH)

  4. Itasca County AMH Case Management Open Form

    Form used to open case management services.

  5. Itasca County CMH Case Management Open Form

    Form used to open case management services.

  6. Itasca County Housing Support Provider Compliance Agreement

    Housing Support provider agreement

  7. Minnesota DHS Professional Statement of Need

    DHS form used to approve or deny funding

  8. MN DHS: SFY 2023 Housing Support Agreement - Community Settings

    Housing supports for community settings.

  9. Online Mandated Reporter Training Question?

    a location for people to send questions about mandated reporting

  10. Online: Adult Mental Health Case Management Referral Form

    Online form to submit referrals for adult mental health case management services.

  11. Online: Child Protection Suspected Child Abuse/ Neglect Reporting Form

    Online form for reporting suspected child abuse/ neglect form

  12. Online: Children's Mental Helath Case Manaegment Client Review

    Review form that can be filled out by the case manager to update the county on how the client is doing

  13. Rule 5 Referral

    Eform used to send a referral in for a Rule 5 to establish if placement is needed in a Rule 5 facility

IMCare

  1. Population Health Management

    Wellness and Prevention Individual Health Appraisal Survey

Itasca County

  1. Affidavit of Restitution

    Access the request for restitution and affidavit form.

  1. Itasca County Rule 79 Adult Mental Health Referral

    Access the Adult Mental Health Referral form.