Welcome to Live Learn Hope Services!

*Before completing the referral, please complete PSON from the current physician*

Caseworkers, please update CSP/CSSP.

Live Learn Hope Services NPI: A478492500

Reason For Submittal*

Initial Eligibility RequestRenewal Eligibility RequestPerson Center Plan Change RequestProvider Change RequestAdditional Transition Unit Exception RequestAdditional Sustaining Unit Exception Request

Is This Person Seeking Moving Expenses?*

YesNo

Moving Expense Needs

Household SuppliesFurniturePacking/MovingApplication Fees/Deposits

By Selecting An Option Below, I Am Attesting This Person Is Leaving This Living Situation:*

Medicaid-funded institutional settingsCurrently homeless and has stayed in a shelter or county-funded emergency shelter (including hotel voucher program or other county-funded emergency housing sites) at some point over the last 12 monthsLeaving a provider-controlled settingN/A

Living Situation*

By Checking This Box, I Am Attesting This Person Is Moving Into Their Own Home*

Yes (Home means a setting that a participant owns, rents, or leases that is not operated, owned, or leased by the provider of services of support)

Housing Status*

TransitioningSustaining

Housing Instability*

HomelessAt- Risk of homelessnessTransitioning from facilityInstitutional level of care/eligible for waiver

Proof of Disability Type*

Professional statement of needState medical review teamMA-DX/MA-BX (Currently on Waiver )Social security income/ social security disability insuranceMedical opinion formAge 65 or older

Assessment Type*

Professional statement of needCoordinated entryMNChoices assessment

Have you seen a physician within the last year?*

YesNo

Has a PSON been completed within the last 90 days?*

YesNo

Upload Completed PSON

Person Centered Plan Type

Housing focused Person Center PlanCoordinated services and Supports Plan

Please verify client's current address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please verify client's mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Name*

First NameLast Name

Client Phone Number*

Please enter a valid phone number.

Client Email*

example@example.com

Client Date of Birth*

Date

Name of Person Completing Form*

First NameLast Name

Phone Number of Person Completing Form*

Please enter a valid phone number.

Email of Person Completing Form*

example@example.com

Where are you moving?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Move Date

Date

Items needing packing (please separate with semicolons)

Insurance Provider

Is the person completing this from the Transition or sustaining provider?*

YesNoSelf

Transition Provider Name

Transition Provider Email

Transition Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Transition Provider NPI/UMPI

Does this individual have additional support resources, such as an IHS worker or mental health advocate, to assist with this process?*

YesNo

If yes, list name, number, email address, and type of service: