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Integrated Community Supports Referral Form

245D Home

ICS

NPI # 1396484820

T1020.UC

Date of Referral

MM slash DD slash YYYY

Referring Agency

NPI/UPMI

Name and Title

Phone

Email Address

Fax

Recipient Information

Client Name

Date of Birth

MM slash DD slash YYYY

Phone Number

PMI #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Living Situation

Own Housing: Lease, Mortgage or Roommating

Service Provider: Foster Care, Group Home

Jail/Prison/Juvenile Detention

Emergency Shelter

Place Not Meant For Housing

Family/Friends Due to Economic Hardship

Hospital/Treatment/Detox/Nursing home

Hotel/Motel

Waiver Type(Required)

CADI

CAC

One Required

Monthly Income Amount

Income Requirement for rental is a total of $1,000.00 Monthly

Please Provide a brief summary of the client, their rental history, income, behaviors, criminal history and services they will need or are receiving:

Eligibility Documents

MnCHOICES Assessment

Coordinated Services and Support Plans (CSP/CSSP)

Social Security Award Letter (SSI/RSDI/SSDI)

Proof of Income

To be submitted with referral

Document Upload

Max. file size: 40 MB.

Documents If Available

Facesheet

Most Recent H&P

Additional Document Upload

Max. file size: 40 MB.

Depending on what referral documents are sent, additional documents maybe requested before we determine if they are eligible for an assessment.

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