Intervention Support Services Referral Application

Intervention Support Services Referral Application
Which Intervention Service is the referral for? (description below)
Positive Support Services: To improve an individual's quality of life by teaching new, adaptive skills and increasing desirable behaviors to reduce challenging behaviors.

Specialist Services: To provide comprehensive and holistic care tailored to an individual's unique needs, such as companionship and interrelationship skills,augmentative communication, community safety training and support, functional motor skills, personal health, and skills to live independently.
Service area:

15 miles away from Bloomington, MN
I live within the service area listed
I'm sorry, we do not have services available in your area. Please check back again.
Client Information:

Please fill out the following information that would pertain to the client who will be receiving services
Person who is submitting referral

First NameLast Name
Client Name

First NameLast Name
Client Gender

Other
Guardian?
Client Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race/Ethnicity:
Primary Language:
PMI number:
County Case Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Housing
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Type of Waiver

Other
Intake preference
Reason for referral (Describe the reason for referral and estimated hours that are needed).
Number of Positive Support Professional hours desired (Required Role, 4 hour minimum)
Number of Positive Support Analyst hours desired (Optional Role)
What hours are you available to see the staff? Staff are generally staffed Monday-Friday between 8 am-6 pm.
I need staff outside of the Monday-Friday 8-6pm availability
Staffing preference for language, gender, or other
Waiver Case Manager Information:

Please fill out the following information that would pertain to the case manager who is responsible for the waiver / billing
Case Manager Name

First NameLast Name
Company Name
Case Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email
example@example.com
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Legal Representative / Guardian Information:

Please fill out the following information if the client has a legal representative, a guardian or is under guardianship.
Legal Representative Name

First NameLast Name
Relationship to client
Legal Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Legal Representative Email
example@example.com
Legal Representative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Care Team / Support System:

Please fill out the following information and list all of the names, relations / titles, and contact information for all care team members and support systems
Care Team / Support Person Name #1   First Name   Last Name

Relationship to client:   eg Family Member

Phone Number:   Area Code   Phone Number

Email:   Email

Address:   Street Address   Address Line 2   City   State   Zip
Care Team / Support Person Name #2   First Name   Last Name

Relationship to client:   eg Family member

Phone Number:   Area Code   Phone Number

Email:   Email

Address:   Street Address   Address Line 2   City   State   Zip
Care Team / Support Person Name #3   First Name   Last Name

Relationship to client:   eg Family member

Phone Number:   Area Code   Phone Number

Email:   Email

Address:   Street Address   Address Line 2   City   State   Zip
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referrer's Signature
Please attach client CSSP and guardian paperwork (if applicable), anything other supporting documents are appreciated but not required

Cancelof
Should be Empty:

Intervention Support Services Referral Application

Service area:

I'm sorry, we do not have services available in your area. Please check back again.

Client Information:

Waiver Case Manager Information:

Legal Representative / Guardian Information:

Care Team / Support System: