Intervention Support Services Referral Application

Intervention Support Services Referral Application
Positive SupportsSpecialist Services
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:

25 miles away from Bloomington, MN
YesNo
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
MaleFemaleOther
YesNo
Client Date Of Birth*

MonthDayYear
Date
Race/Ethnicity:*
Primary Language:*
PMI number:*
County Case Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CRS/Group homeAssisted LivingICS/Supported ApartmentClient lives on their ownFamily home
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Email*
example@example.com
CADIBIDDCACApplicant wishes to privately pay for servicesOther
In person (client at minimum must attend)Remote video (client or guardian) at minimum must attend)Split Intake meeting: Intake should be completed separately for team and client.
Reason for referral (Describe the reason for referral and estimated hours that are needed).
Number of Positive Support Professional hours desired (Required Role)*
Number of Positive Support Analyst hours desired*
What hours are you available to see the staff? Staff are generally staffed Monday-Friday between 8 am-6 pm.
YesNo
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
Please upload supporting documents (Required is CSSP other examples would include MNCHOICES, Diagnostic Assessments)*

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: