Housing Stabilization Intake and Referral Form

Housing Stabilization Intake & Referral Form
To begin, please answer the following:
I am 18yrs of age or over*

YesNo
I have MA (Medicaid) through the State of MN:*

YesNo
I'm sorry, you are currently not eligible for services. Please try again later.
Please provide your PMI (Medical Assistance) number if known
Medical Assistance Expiration Date

MonthDayYear
Date
Please provide your county case number if known
Do you have a waiver or mental health case manager?

YesNo
Case Managers Name /Phone number and email if applicable
My Case Managers Name is

First NameLast Name
Case Managers Email:
example@example.com
Case Manager's Phone:
Please enter a valid phone number.
Waivered Clients Only: Please upload a copy of your Coordinated Service Support Plan (CSSP)

Cancelof

For security deposit & first month rent assistance only
First months rent assistance requested:
Security deposit amount requested:
Address of where you plan to move:
Please detail below who you have already reached out to for assistance, and the current status of that request.
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome

For utility assistance only
# of months owed on utilities
Amount requested for utilities
Name of Utility Company
Account number
Utility Company Phone Number
Please detail below who you have already reached out to for assistance, and the current status of that request.
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome
I have contacted the following agency for assistance: agency name
The outcome of this is/was: outcome

Contacts & References
If I need a reference, I know these people will give me one:
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship
Contact name:   First Name   Last Name
Phone number:   Phone number
How they know me:   Relationship

Non Disclosure Agreement
I First Name* Last Name* , give permission to Affinity Residential Care LLC to disclose information given on this intake form above.

I understand that these forms will be used to coordinate with different service organizations.

I hereby give permission to disclose any of the above information. I have read this release before signing below, and I fully understand the contents, meaning and impact of this non disclosure agreement
Todays date:

MonthDayYear
Date
Signature*

Clear
Please submit a picture of your valid ID*

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Please submit a picture of your Insurance Card

Cancelof
Should be Empty:

Housing Stabilization Intake & Referral Form