Assisted Living/Customized Living Referral Form
Personal Information
Please fill out as much information as possible. This will ensure placement is fast and efficient.
Type of Waiver
*
CADI Waiver
BI Waiver
Elderly Waiver
Private Pay
Specific Options
*
Please Select
Coed
Female Only
Male Only
High Medical Needs
Female Only, High Medical Needs
Male Only High Medical Needs
No preference.
Timeframe Needed
*
IMMEDIATLEY
1-2 Weeks
1 Month
Other
Type of Housing Desired
*
18+
55+
Pets Accepted
Wheelchair Accessible
If multiple options will work. Pleas list which of the above you prefer.
FULL NAME
*
Date of Birth
*
/
Month
/
Day
Year
Date
PMI Number
*
Address
Full Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number(s)
Email Address
example@example.com
Religious & Cultural Preference(s)
Gender Identity
Race/Ethnicity
Medical Equipment, Devices, Adaptive Aides, Technology, Specific Medical Needs
*
Guardian Status
*
Self
Private
Public
Under Commitment
Current Living Situation
*
Own housing: Lease, Mortgage or Roommate
Service Provider: Foster Care or Group Home
Hotel Motel
Jail/Prison/Juvenile Detention
Family/Friends due to Economic Hardship
Hospital/Treatment/Detox/Nursing Home
Emergency Shelter
A Place not meant for Housing
Other
Mobility
Some of our homes have rooms that are accessible, but not to the entire house, just one floor. Other homes are made accessible with the use of chair lifts. Please answer the following questions so we can provide you with a list of the most appropriate settings for your individual’s specific needs
Does this person have mobility concerns?
*
yes
No
Does this person use OR could they use any of the following to assist with mobility/accessibility? (Cane, Walker, Wheelchair, Scooter, Chair lift for stairs, Hoyer Lift) If yest please list what is used below.
Would they be open to moving into a home if they only had access to one floor of the home, due to the limited accessibility of the home?
Yes
No
Residential Assisted Living and Customized Living Openings List (Please, Check all that apply)
Simple Health Services tries to keep this list as up to date as possible. We will be in touch to confirm your selections are still available.
55+ ACCESSIBLE
5336 NORTHPORT DRIVE, BROOKLYN CENTER, MN 55429.
10816 CEDARBRIDGE AVENUE, BURNSVILLE, MN 55337
8256 SCOTT AVENUE NORTH BROOKLYN PARK, MN 55443
2116 73RD COURT NORTH, BROOKLYN PARK, MN 55444
1214 AUTUMN STREET, ROSEVILLE, MN 55113
55+ NOT ACCESSIBLE
8256 SCOTT AVENUE NORTH BROOKLYN PARK, MN 55443.
1620 WILKING WAY, SHAKOPEE, MN 55379 (EW NOT ACCEPTED)
7211 CAMDEN AVE NORTH, BROOKLYN CENTER, MN 55430
208 14TH STREET WEST HASTINGS, MN, 55033
8501 BROOKLYN BLVD, BROOKLYN PARK, MN 55428
7557 BRUNSWICK AVENUE NORTH, BROOKLYN PARK, MN 55443
4506 IMPATIENS AVENUE NORTH, BROOKLYN PARK, MN 55443
18+ ACCESSIBLE
1013 WEST RIVER ROAD, CHAMPLIN, MN, 55316.
6044 CLINTON AVENUE SOUTH, MINNEAPOLIS, MN 55419.
6426 109TH PLACE NORTH, CHAMPLIN, MN 55316.
7900 DOUGLAS DRIVE NORTH, BROOKLYN PARK, MN 55443.
10025 COLFAX AVENUE SOUTH, BLOOMINGTON, MN 55431
7166 205th STREET WEST, LAKEVILLE, MN 55044
4946 JACKSON STREET NE, COLUMBIA HEIGHTS, MN 55421
7243 MORGAN AVENUE NORTH, BROOKLYN CENTER, MN 55430
7166 205TH STREET WEST, LAKEVILLE, MN 55044
9220 207th STREET WEST, LAKEVILLE, MN 55044
3835 SARATOGA LANE NORTH, PLYMOUTH, MN 55441
11409 SWALLOW STREET NW, COON RAPIDS, MN 55433
18+ NOT ACCESSIBLE
9633 HALE AVENUE SOUTH COTTAGE GROVE MN, 55016
3935 5th AVENUE SOUTH, MINNEAPOLIS, MN 55409
3301 84TH AVENUE NORTH BROOKLYN PARK, MN 55443
1540 CONWAY STREET, SAINT PAUL, MN, 55106
18+ NOT ACCESSIBLE - MALE ONLY
3693 GROVNER ROAD, NORTH, OAKDALE, MN 55128.
18+ ACCESSIBLE - MALE ONLY
6426 109TH PLACE NORTH, CHAMPLIN, MN 55316
18+ NOT ACCESSIBLE- FEMALE ONLY
7124 16TH STREET NORTH, OAKDALE, MN 55128.
15236 GERMANIUM CIRCLE NW, RAMSEY, MN 55303
Team Contact Information
*Please Include Name, Company Name, Best Contact Number & Email Address in the Spaces Provided*
Waiver Case Manager: Company Name, Best Contact Number & Email Address
*
Note: if you do not provide contact info we will have no way to move forward.
Referring Party: Company Name, Best Contact Number & Email Address*If different from Waiver Case Manager
Legal Representative or Guardian: Company Name, Best Contact Number & Email Address
The Current CSSP & MNChoice Assessment below, or to our Community Referral Coordinator, Samantha Tschida, at Samantha@simplehealthservices.org
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