Please Complete This Referral Form and Submit It to the Intake Coordinator(S) Along With

Community Involvement Programs

Supported Living Partnerships (SLP) Referral Form

Please complete this referral form and submit it to Deb Procknow,SLP Program Manager(Fax: 612-547-0556), along with any available social history, assessments or physical information on the individual. TheProgramManager will assign staff and arrange an intake for services. The length of time for the referral process varies depending on staff availability. You will be informed as soon as possible if immediate staffing is not available. If you have anyquestions regarding services or staffing, please contactDeb Procknow, SLP Program Manager, or (612) 362-4435.

Referred By:Name: ______Phone Number: ______

Agency: ______

Address: ______

City: ______Zip Code: ______

E-Mail Address: ______Fax: ______

Person’s Information

Person’s Name: ______

SS#: ______DOB: ______

Working Phone #: ______ Insurance/PMI/MA#: ______

Medicare #:______

Address: ______

City: ______Zip Code: ______

Diagnosis: ______Diagnostic Code(s) (if known) :______

______

Any Health Concerns: ______

Guardian (if applicable)phone & address: ______

______

Emergency (if other than Guardian)or Alternate Contact phone & address: ______

______

Rep Payee (if person has one) address & phone:______

______

Services requested: ______

______

Is 24 Emergency Assistance Requested:

NO

YES

Funding Source (payor): DD Waiver CADI Waiver SILS BI Waiver Private Pay

Other ______

Hours of services per week being requested (exclusive of daily contact/24 hour emergency assistance): ______**

**Please note: a Service Authorization must be received within 45 days or services may be discontinued. Questions regarding Service Authorizations, Cost Proposals, etc. should be directed to CIP’s Authorization Specialist: Jon Bergquist, 612-362-4472 or .

Case Manager:Name: ______Phone Number: ______

Agency: ______

Address: ______

City: ______Zip Code: ______

E-Mail Address: ______Fax: ______

Does person have a spend down?

NO

YES, A “Participant agreement for payment of Medical Spend-down” must be signed by person at time of Intake or services may be discontinued.

NOT KNOWN

Is the person receiving services from any other provider (i.e. PCA, Home Health, ARMHS)?

NO

YES

If yes, provider name, phone number & type of service: ______

______

Any day treatment or work schedules?

NO

YES, please explain :______

NOT KNOWN

Any suicidal or self-inflicting injury history?

NO

YES, please explain :______

NOT KNOWN

Any history of violent, aggressive, or other anti-social behavior?

NO

YES, please explain :______

NOT KNOWN

Any cultural issues or concerns?

NO

YES, please explain :______

NOT KNOWN

What are the Outcomes you are requesting CIP to support? Please send CSSP (ISP/CSP) as soon as possible.

1. ______

2. ______

3. ______

4. ______

Are there any immediate concerns (i.e. impeding eviction)?

NO

YES, please explain :______

NOT KNOWN

Is there a gender preference regarding the staff CIP will send to their home?

NO PREFERENCE

MALE

FEMALE

NOT KNOWN

Additional comments or information:

______

______

______

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