CRS/ICS - Application Form

CRS/ICS - Application Form
To save your progress to complete later, simply click "Save" at the bottom and you can finish off where you started. If you have any questions please call the Affinity Care Office on 952-217-4750
Referral's Name*

First NameLast Name
Gender Pronouns*
Referral's Date Of Birth*

MonthDayYear
Date
Referral's Email
Referral's Phone Number
Please enter a valid phone number.
Gender*

MaleFemaleOther
Preferred placement date*

MonthDayYear
Date
If immediate placement needed, why?
Is the person on an Active CADI or DD waiver?*

YesNo
Does the applicant have a guardian?*

YesNo
What is the person's current living situation*
Reason for leaving current living situation?*
Living arrangement sought*
Integrated Community Supports (ICS) Community Residential Services (CRS)
Income per month (SSI/SSDI/Wage)
if none enter "0"
Per month MSA or Housing Support
if none enter "0"
Per month SNAP or other*
if none enter "0"
Support or Service Animal*

YesNo
Are you able to provide Support/Service animal documentation and immunization records?

YesNo
If "yes" to Support of Service Animal - what type and breed?
Name of Person Making Referral*

First NameLast Name
Referring Person's Phone Number*
Please enter a valid phone number.
Referring Person's Email*
Referring person's relationship to the Applicant*
Upload: Support plan/CSSP*

Cancelof
Medication list (if CRS)

Cancelof
Other files

Cancelof
By signing below, I certify that the information included in this form is correct to the best of my knowledge.
Date*

MonthDayYear
Date
Signature*

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