Transitional Services Referral Form

Transitional Services Home

Individuals are eligible if they meet the following criteria:

Must be waiver eligible (CADI, CAC, DD & BI waiver) and 18 years or older
Must not have received transitional services in the last 3 years
Moving from an eligible setting to their own home or an integrated community supports setting
Moving to a setting where these items and expenses are not normally furnished
Not able to access transitional services from other funding sources (e.g., community nonprofit organizations)
Transitional Services can be authorized up to 45 days after transition
Please view the DHS CBSM website for full details: CBSM – Transitional services – BI, CAC, CADI and DD (state.mn.us)

OCS Transitional Services Provision:

OCS requires a Service Agreement to be authorized before any service is provided
OCS will communicate only with housing and waiver case managers making the referral. Case Managers will be expected to communicate any and all necessary information to the client throughout the service. Clients contacting us will be referred back to their waiver case manager
Incomplete or referrals made less than 10 days before the move date, may be subject to delay or denial
We will only purchase items that are listed on this referral. If it is not marked or noted it will not be purchased or paid out
Due to high cost of labor and essential items, deposits over $500 that need all parts of the service (furniture, household and movers) may be subject to limited amount of TS coordination time and delayed purchases, as movers’ invoices and security deposits are prioritized
Letter of Guarantee will be sent out before the move, security deposits will be sent once claim is submitted

Please fill out ALL following sections

Date Referral Made

Move Date

Client Name

Date of Birth

Phone Number

PMI #

Waiver

Referral Contact Information

Referring waiver manager name

Phone Number

Housing Case Manager Name

Phone

Guardian Name/Emergency Contact

Phone

Previous Placement/Address

Address

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

Phone

Unit Size Moving Out Of

Efficiency

Studio

Facility

1 BR

2 BR

Other

Storage Facility

Name

Address

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

New Home/Placement

New Address

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

Unit Size Moving to

Efficiency

Studio

Facility

1 BR

2 BR

Other

Property Manager Name

Phone

Security Deposit/Application Fee

Security Deposit Amount

Application Fee Amount

Do we need to send a letter of guarantee?

Yes

Check made out to

Check Mailing Address

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

Move Details – Please Provide details regarding move

Moving Expense

Not to Exceed $1,700 of the allowable $3,000

Move Personal Items from previous home, facility or storage unit

Yes

One-time pest and allergen treatment of home

Yes

Blinds or window coverings

Yes

If Yes for Blinds or Windows – Please provide number and measurements of the windows

Preference of Essential Furniture

Not to exceed $1,000 of the allowable $3,000 *Allotted budget does NOT allow to get all items listed *Dinning set with chairs are low in stock and maybe subject to delayed arrival or availability

Furniture For Moving

Bed

Sofa/Couch

Dining Table

Dresser

Nightstand

TV Stand

Are you okay with used items?

Yes

Bed Size

Bed Pieces

Bed Frame

Mattress

Box Spring

Sofa/Couch

2 Cushion Sofa

3 Cushion Couch

Dining Table

2 chairs/bench

4 chairs/bench

Preference of Household Supplies

Not to exceed $300 of the allowable $3,000. This $300 budget does not allow for all the following items:

Bedroom

1 pillow

Hangers

Clothes Hamper

Bed in a bag

Bathroom

Garbage Can

Shower Curtain w/rings

Toothbrush Holder

Toilet Brush

Toilet Paper

Kitchen

Cleaning Supplies

Please list items that can be removed if not all items fit in the budget

Cancellation and Weather Release Notice

Opportunity Community Services reserves the right to reschedule, postpone or delay the Transitional Services due to unforeseen circumstances (staff illness/emergency, equipment issues, client illness/hospitalization, etc.) We will take every measure to prevent these barriers from effecting the move day before making a final decision.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

Opportunity Community Services will not move or deliver under these weather conditions in the county of pick up or drop off: tornado warning, severe thunderstorm warning, temperature below -10 degrees, blizzard, and white out conditions. If the move is canceled due to weather, OCS will work with your case managers to set up a new move date. OCS will not be responsible for any extra fees that may occur because of this cancelation.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

Opportunity Community Services can move/deliver in weather conditions (rain, snow, sleet, etc.) with your consent. I understand that OCS is not responsible for the items getting damaged or wet due to this weather. OCS does not provide items to cover belongings being moved or protect them from the above weather conditions.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

Person Served Signature

First Last

By signing above, you are acknowledging that you understand and agree to the cancellation and weather policies

Today's Date

Waiver Case Manager Signature

First Last

By signing above, you are acknowledging that you understand and agree to the cancellation and weather policies

Today's Date

Transitional Services Move Agreement

I consent to the following: Purchase of the items in this referral will be made through my transitional services funding. I understand the assigned OCS transitional services coordinator will be shopping on my behalf based on the selections in this referral. I understand that OCS uses specific vendors for furniture and household items, and will not purchase furniture or household items outside of those vendors (Hotel Liquidators, Walmart, and Amazon). OCS cannot purchase any electronics per DHS. OCS does not reimburse for any payments made by the client or dispose of any of the client’s personal belongings. All sales are final. OCS is not responsible for replacing or returning broken or defective items that are purchased. Original receipts will not be provided after purchase. You have 3 days post move to report any damage to your personal belongings during the move (only applicable for inside movers). If outside movers are hired you will need to work directly with them to resolve damages to personal belongings. Your case will be billed and closed out 4 days post move. After claim submission to DHS, no cases will be reopened for additional purchases.

Person Served Signature

First Last

Date

Waiver Case Manager Signature

First Last

Date

Contact Us Today!

We are here to help you move your life forward. Fill out the contact form to get started.

Individuals are eligible if they meet the following criteria:

OCS Transitional Services Provision:

**Please fill out ALL following sections **

Referral Contact Information

Previous Placement/Address

Storage Facility

New Home/Placement

Security Deposit/Application Fee

Moving Expense

Preference of Essential Furniture

Preference of Household Supplies

Cancellation and Weather Release Notice

Transitional Services Move Agreement

Contact Us Today!

Please fill out ALL following sections