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
DD Waiver
Specific Options
*
Please Select
Coed
Female Only
Male Only
High Medical Needs
Female Only, High Medical Needs
Male Only High Medical Needs
No preference.
Age/Options
*
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
Medical Equipment/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
Does this person have mobility concerns?
*
Yes
No
(Cane, Walker, Wheelchair, Scooter, Chair lift for stairs, Hoyer Lift) If yes please list what is used below.
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 referrals@generouslivingservices.com
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