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Targeted Case Management Referral Form
Your Name
Date of birth
Your Gender
Male
Female
Level of Tier Being Referred For:
Transitioning
Sustaining
Your Home Address (Street address, street address 2, city, State, Zip)
Your Phone Number
Your Email
County of Residence
Primary Disabilities
Do you have a guardian?
Yes
No
If you do you have a guardian, what is their name and number?
PMI #
Current Status of Consumer
Stable Income
Currently In Stable Housing
Previous Evictions/Felonies
Emergency Housing Needed
Current Living Situation
Own Housing
Foster Care/Group Home
Emergency Shelter
Jail/Prison/Juvenile Detention
Hospital/Treatment/Detox
Current Level of Instability
Homeless
At Risk of Homelessness
Transitioning From Facility
Institution Level of Care
Eligible For Waiver
Disability Type
SSI/SSDI
Developmental Disability
Substance Use Disorder
Injury or illness with Extended Incapacitation
Mental illness
Does Your client qualify for moving expenses through HSS?
Moving From Medicaid Institutional Setting
Leaving a Provider Controlled Setting
Currently Homeless/has stayed at a shelter at some point over last 12 months
If your Client Does not qualify for HSS moving Expenses are you seeking Transitional Services based on waiver eligibility? (Yes/No)
Yes
No
If yes, identify what services are needed:
Assistance Coordinating/Setting Up The Move
Household Items/Furniture
Damage Deposit
Referring Agent (First Name, Last Name, Phone Number, Email, Organization)
Upload Supporting Documents
Supporting Documents: Person Centered Plan
Housing Focused Person-Centered Plan
Supporting Documents: Assessment Type
Professional Statement of Need
Supporting Documents: Proof of Disability
Professional Statement of Need
Submit