Referral

African Families Development Network

+612-724-0000

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info@afdnminnesota.org

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2446 15th Ave S Minneapolis

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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

ICS REFERRAL FORM

Application Form

ICS REFERRAL FORM

Personal Information
Waiver Case Manager Information
Level of Need
Legal Status & Legal Representative Contact Information

Personal Information

First Name:

Last Name:

M.I.:

PMI No:

Date of Birth:

Gender:
Male Female Prefer not to answer Other

Race:

SSN:

Address:

City:

Zip code:

Phone Number:

Cell Number:

E-mail address:

Diagnosis Codes

Referral Date:

Waiver Case Manager Information

First Name:

Last Name:

Address:

City:

Zip code:

E-mail Address:

Office number:

Office Fax:

Office number:

Agency Name:

Would you like to be updated on all assessment scheduling ?
Yes No

Primary Emergency Contact Information

First name:

Last name :

Best Contact Number:

Relationship:

Special Needs

Are there any known cultural consideration needs?
Yes No

specify:

Allergies:

Other (be specific):

Level of Need

Does this person have a criminal background?
Yes No

Are you aware of any drug/ alcohol use?
Yes No

Does this person use the following? (mark all that apply)
Walker Cane Wheelchair

Other:

Does this person have an income source?
Yes No (If yes, enter information below)

Type of income:

Amount: $

Type of income:

Amount: $

Type of income:

Amount: $

Does this person currently have a lease?
Yes No If so, when will it end?

How soon does this person want/need to move? (exact date not necessary)

Other important notes (please be specific):

Care Preferences

Will this person need Transitional Services? (choose all that apply)
Deposit Movers Household items Furniture

Legal Status & Legal Representative Contact Information

Legal Status & Legal Representative Contact Information
responsible for self under guardianship (complete section below) under commitment

First name:

Last name:

Address:

City:

Zip code:

Best Contact Number:

Fax Number:

Email:

Case Manager Signature: Choose a file

Max. size: 32.0 MB

Date:

**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

Some required Fields are empty
Please check the highlighted fields.

Application Form

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

First Name

Last Name

Applicant’s Date Of Birth

Applicant’s Email

Applicant’s Phone Number

Area CodePhone Number

Applicant’s Current Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Gender
Male Female Other

Primary Language Spoken

List all present medical diagnosis (Please keep in mind we are NOT wheelchair accessible at this time

What is the applicants current living situation
With parent/guardian Private Home / Apartment Group HomeOther

Does the client currently receive services? Please include amount of hours for any PCA, Homemaking, IHS, or ICS services

Reason for leaving current living situation?

What city is the applicant interested in applying to
Minnetonka Minnetonka

Does the applicant have any pets?

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?
Yes No

Does the applicant own their own vehicle?
Yes No

Does the applicant plan to have a roommate?
Yes No Maybe \ possibly

Part B: Legal Background

Has the applicant ever been arrested?
Yes No

Has the applicant ever been convicted of a crime?
Yes No

If Yes to the above, please state if it was a misdemeanor or felony. Please describe and include dates and the current status of case.

Part C: Financial

What type of waiver does the applicant have?
CADI BI DD CAC Waiver Pending – Assessment Completed Applicant wishes to privately pay for servicesOther

What is the current county of financial responsibility?

Primary income sources
MSA Cash Assistance Food Support Income from a job SSI RSDI SSDI Adoption Assistance Trust GRH Alimony Child Support GA MFIP Unemployment Workers CompensationOther

Does the applicant have any spend downs or garnishments? If so – please detail.

Financial management (check all that apply)
Manage their own finances A family member / friend helps them manage finances Has a Rep-PayeeOther

What is the applicants total monthly income from all sources? Please upload any supporting documentation at the end of this application. Choose a file

Max. size: 32.0 MB

Part D: Referral Information

How immediate is placement needed? If less than 4 weeks, why?

Name of Referral

Referring Person’s Phone Number

Area CodePhone Number

Referring Person’s Email

Referring person’s relationship to the Applicant (select all that apply)
I am the applicant / client – I’m applying for myself Family member / Friend CADI Case Manager Case Manager Social Worker Housing Support Specialist Mental Health Case Manager Counselor ARMHS County Case WorkerOther

Living arrangement sought
ICS/Supportive Apartment Assisted Living or Customized LivingOther

Case Manager Name

Case Manager Email

Case Manager Phone

Area CodePhone Number

Location #1

Applicant lived at;

DateUntil

End Date

The contact First Name for this location is

The contact Last Name for this location is

Location address is

Street Address

Address Line 2

City

State

Zip

Contact email

Contact Phone

Area CodePhone Number

Has the applicant had an involuntary service termination within the past 12 months?
Yes No

Has the applicant been evicted within the last 12 months?
Yes No

Location #2

Applicant lived at;

DateUntil

End Date

The contact First Name for this location is

The contact Last Name for this location is

Location address is

Street Address

Address Line 2

City

State

Zip

Contact email

Contact Phone

Part F: Functional Information

Does the applicant have a history of recurrent violent behaviours in the last 12 months? (Examples include Physical Aggression, Agitation, Verbal Aggression, Sexual Coercion or Aggression).

Does the applicant have a history of drug or alcohol use in the past 12 months?

Does the applicant have a history of Self injurious behaviors or Suicidal Ideation and/or Attempt within the last 12 months?

Does the applicant have a history of property destruction within the last 3 years?

Does the applicant have ability to safely utilize appliances (Gas stove, Electric stove, Microwave)

Has the applicant been hospitalized in the past 12 months?

Has the applicant had any falls in the past year?

Does the applicant have a history of medication non-compliance in the past 12 months?

Are there any other safety or behavioural concerns to consider for this applicant?

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 Choose a file

Max. size: 32.0 MB

Upload: MN Choices Choose a file

Max. size: 32.0 MB

File Upload: Facesheet Choose a file

Max. size: 32.0 MB

Upload: SSI Letter to support income amount or any other document to support current income. Choose a file

Max. size: 32.0 MB

File Upload: Any other documents you deem important Choose a file

Max. size: 32.0 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

First Name

Last Name

Relationship to applicant

Signature Choose a file

Max. size: 32.0 MB

Date

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.

Resident / Resident Representative Full Name

Relationship to resident

Signature Choose a file

Max. size: 32.0 MB

Signed on

Services Needed

Check each box that applies

Community Participation

Community Mobility, accessing the community.

Asking for help when in the community.

Safety in the community.

Finding volunteer activities in the community.

Community resources, social or leisure activities.

Pedestrian Safety

Accessing public transportation.

Maintaining appropriate social behavior, in the community.

Finding a place of employment.

Finding a place where I can practice my beliefs.

Assistance staying safe in my community.

Support maintaining friendships and family relationships.

Health Safety and Wellness

Scheduling appointments.

Setting up rides to appointments.

Ordering medications

Picking up medications

Finding a workout gym.

Assistance with hygiene tasks.

Help at doctors’ appointments.Other

Household Management
Planning a special diet. Making a grocery List. Grocery Shopping. Support with accessibility in my living environment. Support with laundry Calling for home maintenance. Cooking, and safe food handling. Setting up Cleaning Schedule Cleaning, home and medical equipment Guidance to identify routine household chores and maintenance. Getting Mail Organizing Mail Organizing Mail Setting up household budget. Completing recertification paperwork. Paying bills Balancing money checkbook, savings. Organizing Home, to meet my needs.Other

Adaptive Skills

Coordinating services between providers.

Safety at home.

Problem solving.

Support strategies for selfsufficiency.

Support with verbal interactions with others.

Keeping an appointment book, or calendar.

Maintaining appropriate interactions with Staff.

Crisis Prevention skills.

Support with challenging behaviors.

Following housing and lease rules.

Following written directions

Following verbal directions

Other assistance with adaptive skills. Please comment

belowOther

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Disclaimer: The information on this website is for general information purposes only. Nothing on this site should be taken as healthcare advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, a healthcare professional-patient relationship. We do our best to keep information accurate and up to date, however mistakes do happen, and we cannot make guarantees regarding the accuracy of our information. We are not liable for any information on this website or your reliance upon it.