Resources
The following website links have been compiled by African Community School Resources. Our agency is not directly affiliated with these organizations however we have gathered this information as we believe they are all very useful agencies that can provide resources and assistance to you. Please visit their websites for more information. If you would like our help navigating these websites or understanding the information please call today at 612.454.1488
- Personal Information
- Waiver Case Manager Information
- Level of Need
- Legal Status & Legal Representative Contact Information
Personal Information
Gender:
Waiver Case Manager Information
Would you like to be updated on all assessment scheduling ?
Primary Emergency Contact Information
Special Needs
Are there any known cultural consideration needs?
Level of Need
Does this person have a criminal background?
Are you aware of any drug/ alcohol use?
Does this person use the following? (mark all that apply)
Does this person have an income source?
Does this person currently have a lease?
Care Preferences
Will this person need Transitional Services? (choose all that apply)
Legal Status & Legal Representative Contact Information
Legal Status & Legal Representative Contact Information
Case Manager Signature:
Max. size: 128.0 MB
**At time of referral, we ask that you submit the individuals Face Sheet, CSSP, MNChoice and any other supporting documents (if you have them available) for review
Please check the highlighted fields.
Please note, answering yes will not necessarily disqualify you.
Please provide below information or attach county referral form
Please provide information relating to the last 12 months.
For any of the following questions, if your answer is no – simply enter “Unknown” or “N/A” If yes, please explain.
- Part A
- Part B
- Part C
- Part D
- Part F
Part A: Applicant Personal Information
Applicant’s Name
Gender
What is the applicants current living situation
What city is the applicant interested in applying to
Clients with support or emotional support animals will need to request a reasonable accommodation and provide supporting documentation to support the request.
Does the applicant have a driver’s license?
Does the applicant own their own vehicle?
Does the applicant plan to have a roommate?
Part B: Legal Background
Has the applicant ever been arrested?
Has the applicant ever been convicted of a crime?
Part C: Financial
What type of waiver does the applicant have?
Primary income sources
Financial management (check all that apply)
What is the applicants total monthly income from all sources? Please upload any supporting documentation at the end of this application.
Max. size: 128.0 MB
Part D: Referral Information
Referring person’s relationship to the Applicant (select all that apply)
Living arrangement sought
Location #1
Has the applicant had an involuntary service termination within the past 12 months?
Has the applicant been evicted within the last 12 months?
Location #2
Part F: Functional Information
Upload your files
Please upload the following documents to support your application. Each of these documents are required upon acceptance into Mn Corporate Housing’s programs. If you do not add it now, you will be able to add it later but this will delay your application in being processed. There will be an authorization to release information form to sign on the next page
Upload: CSSP
Max. size: 128.0 MB
Upload: MN Choices
Max. size: 128.0 MB
File Upload: Facesheet
Max. size: 128.0 MB
Upload: SSI Letter to support income amount or any other document to support current income.
Max. size: 128.0 MB
File Upload: Any other documents you deem important
Max. size: 128.0 MB
Declaration By signing below, I certify that the information included in this form is correct to the best of my knowledge.
Name of person completing this form
Signature
Max. size: 128.0 MB
This completes the Referral Housing Application. The next step is to sign the release of information so that we can begin to process your application. Release of Information Authorization Please read and sign the following so that we can begin to process your application.
I have reviewed the Notice of Use and Disclosure Practices. I understand that the requested Protected Health Information, criminal background information, and rental history will be used by American Home Health Care for the purpose of American Home Health Care. I hereby authorize verbal and written communication from American Home Health Care and in addition, agree to release: The following portions of my clinical record: History and Physical Discharge Summary
Consults Plans of Care Current/ Past Progress Notes Mental Health Records Chemical Dependency Records Operative Reports Health Care Directives Medication List (including Pharmacy Communication) Physician’s Orders Flow Sheets POLST (Health Care Directive) Laboratory Results (All) Radiology Reports (All) And the following portions of other records to Affinity Residential including: Criminal Background Check via BCA or other sources Rental History Verifications within the last 5 years Case Management Records Please read through the declaration below and sign and date at the bottom. I understand that the records will be used to continue evaluation or treatment, coordinate services, and determine eligibility for services. I understand that my records are protected by data privacy regulations. Alcohol and drug abuse records may be protected by Federal Law (42 CFR Part 2). These records cannot be released without my consent unless specifically directed by law. I understand that I have the right to refuse to sign this consent. I understand that I may withdraw or revoke this consent at any time if the action it authorizes has not been carried out. I understand that this consent expires one year from the date I signed it. A copy of this authorization shall be considered as effective and valid as the original.
Signature
Max. size: 128.0 MB
Services Needed
Check each box that applies
Community Participation
Health Safety and Wellness
Household Management
Adaptive Skills
Please check the highlighted fields.
Housing Resources
What is Section 8 Housing? Section 8 is a government-funded program that helps low-income households pay the rent on private, market-rate rental units. Learn easy ways to make a rental unit more accessible, about reasonable accommodation for people with disabilities, and more! Learn about accessibility and see tips on overcoming criminal, credit, rental history, and other barriers.
Connects You Housing, Emergency Shelter, Emergencies, Utility Assistance, Employment and Financial Assistance. United Way 2-1-1 provides free and confidential health and human services information for people in Minnesota. We’re here 24 hours a day, 7 days a week to connect you with the resources and information you need. Whether you are in crisis, or need a little support, we’re here to help.
The mission of the Minneapolis Public Housing Authority (MPHA) is to promote and deliver quality, well-managed homes to a diverse low income population and, as a valued partner, contribute to the well-being of the individuals, families and community we serve.
Providing Safe Affordable Housing to Low Income Residents. St. Paul public housing rental units are well maintained and fully occupied (consistently over 99%), providing safe, affordable housing to about 10,000 low income residents. The PHA has received HUD’s “High Performer” rating each year under the “Public Housing Management Assessment Program” (PHMAP).
Community Resources
Every person who participates in an ARC program or project will have a better chance to take control of their life and achieve self sufficiency. American Refugee Committee is and always has been about amazing global citizens taking action to change our world. More than 35 years ago, Chicago businessman Neal Ball started ARC. He recruited a volunteer relief team who deployed to the Thai-Cambodian border.
Each year, the International Institute assists over 1,000 refugees, asylees and immigrants to navigate the process of permanent residency, citizenship and other immigration procedures. Helping New Americans achieve self-sufficiency and full membership in American life. The Institute supports this mission by providing linguistically and culturally accessible services that enable every New American.
The Minnesota Council of Churches is your partner in living out your faith in your community. The Minnesota Council of Churches is committed to building respectful communities in Minnesota. The Unity and Relationships Program creates the foundation for the common good by building and nurturing interdependent relationships within and among religious communities.
Legal Referrals
The Advocates provides access to free legal services in approximately 1000 immigration cases annually. Creates and maintains lasting, comprehensive, and holistic change on a local, national, and global scale. Volunteers, partners, supporters, board members, and staff implement international human rights standards to promote civil society and reinforce the rule of law.
Providing direct legal assistance to low income people through a network of local offices and programs. A client specialist is available to assist you Monday thru Friday 8:30am to 4:30pm. You will be asked a series of questions regarding your legal issue.
Medical Referrals
To guide refugees and immigrants in the journey toward self-determination and social equality. CAPI USA is an immigrant-led, nonprofit organization that is dedicated to helping Minnesota’s newest refugees and immigrants gain access to jobs, housing, food, health education, youth and senior social services in order to promote economic independence, self-determination and social equality.
Dedicated to improving oral health of children and families with low incomes by providing accessible treatment and education to our diverse MN community . Children’s Dental Services’ (CDS) main office on Broadway Street in Northeast Minneapolis has ten operatory chairs and offers both evening and Saturday appointments.
Community-University Health Care Center (CUHCC) opened its doors in 1966 to provide primary care services to children and low income families in South Minneapolis for acute illness and injury, prenatal care, well-child care, family planning and child spacing, chronic disease management, and more.
Crown Medical Support Services is a 501(c)(3) organization created as a vehicle to provide adequate medical services to those who are without sufficient images to pay for them via insurance or otherwise. Crown Medical Center is a high quality, people-oriented, healthcare center incorporated in the State of Minnesota. The Crown Medical Centers are open to anyone specialty.
Wellshare International Health Volunteers (IHVO) is an independent, not for profit, humanitarian medical aid organization whose primary purpose is to establish an accessible repository of physicians, dentists and other medical experts who have the requisite skills and interest to assist in domestic and international short term medical relief projects.
Translation and Interpreting
Professional Somali translations and Interpreting to discerning clients across the world. With proven methods to produce all Somali Transalation and interpreting to the highest possible linguistic standards, we are the only partner you will need to enable you to communicate effectively to your Somali clients.