Revised: 9/29/17
Community Involvement Programs
Supported Living Partnerships (SLP) Referral Form
Please complete this referral form and submit it to Deb Procknow, SLP Program Manager (Fax: 1+612-217-1238), along with any available social history, assessments or physical information on the individual. The Program Manager will assign staff and arrange an intake for services. The length of time for the referral process varies depending on staff availability. You will be informed as soon as possible if immediate staffing is not available. If you have any questions regarding services or staffing, please contact Deb Procknow, Community Services Program Manager, at or (612) 248-8645.
Referred By: Name: ______Phone Number: ______
Agency: ______
Address: ______
City: ______Zip Code: ______
E-Mail Address: ______Fax: ______
Client Information
Client’s Name: ______
SS#: ______DOB: ______
Working Phone #: ______ Insurance/PMI/MA#: ______
Medicare #:______
Address: ______
City: ______Zip Code: ______
Diagnosis: ______Diagnostic Code(s) (if known) :______
______
Any Health Concerns: ______
Guardian (if applicable) phone & address: ______
______
Emergency (if other than Guardian)or Alternate Contact phone & address: ______
______
Rep Payee (if client has one) address & phone:______
______
Services requested: ______
______
Is 24 Emergency Assistance Requested:
q NO
q YES
Funding Source (payor): DD Waiver CADI Waiver SILS BI Waiver Private Pay
Other ______
Hours of services per week being requested (exclusive of daily contact/24 hour emergency assistance): ______**
**Please note: a Service Authorization must be received within 45 days or services may be discontinued. Questions regarding Service Authorizations, Cost Proposals, etc. should be directed to CIP’s Authorization Specialist: Jon Bergquist, 612-362-4472 or .
Case Manager: Name: ______Phone Number: ______
Agency: ______
Address: ______
City: ______Zip Code: ______
E-Mail Address: ______Fax: ______
Does client have a spend down?
q NO
q YES, A “Client agreement for payment of Medical Spend-down” must be signed by client at time of Intake or services may be discontinued.
q NOT KNOWN
Is the client receiving services from any other provider (i.e. PCA, Home Health, ARMHS)?
q NO
q YES
If yes, provider name, phone number & type of service: ______
______
Any day treatment or work schedules?
q NO
q YES, please explain :______
q NOT KNOWN
Any suicidal or self-inflicting injury history?
q NO
q YES, please explain :______
q NOT KNOWN
Any history of violent, aggressive, or other anti-social behavior?
q NO
q YES, please explain :______
q NOT KNOWN
Any cultural issues or concerns?
q NO
q YES, please explain :______
q NOT KNOWN
What are the Outcomes you are requesting CIP to support? Please send CSSP (ISP/CSP) as soon as possible.
1. ______
2. ______
3. ______
4. ______
Are there any immediate concerns (i.e. impeding eviction)?
q NO
q YES, please explain :______
q NOT KNOWN
Is there a gender preference regarding the staff CIP will send to their home?
q NO PREFERENCE
q MALE
q FEMALE
q NOT KNOWN
Additional comments or information:
______
______
______
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