REQUIRED DOCUMENTATION

To qualify for Housing Stabilization Services (HSS), a referral MUST include the following:

ASSESSMENT

MNChoices, Coordinated Entry, or Professional Statement of Need (PSN) - Cannot be older than nine (9) months.

PROOF OF DISABILITY

Professional Statement of Need (PSN), SSI/SSA Benefit Letter, Medical Option Form, ID showing age 65+

PERSON-CENTERED PLAN

Housing-Focused Person-Centered Plan, Coordinated Care Plan (seniors)

If your client has a Coordinated Services & Supports Plan (CSSP) with Smooth Transitions MN LLC (NPI: 1730734765) as the HSS Provider, this may serve as their Assessment, Proof of Disability, and Person-Centered Plan.

REFERRAL FORM

First Name

Last Name

Date of Birth (DOB)

MA/PMI Number

Phone

Address

ICD-10 Codes (Diagnoses Codes)

Guardian Name (if applicable)

Guardian Phone

Guardian Email

Representative (Rep) Payee Name (if applicable)

Rep Payee Phone

Rep Payee Email

Case Manager (CM)/Housing Consultant Name

CM/Consultant Phone

CM/Consultant Email

Transitioning: Services that assist a person to plan for, find and move to a home in the community.

Sustaining: Services that supports a person to maintain living in their home in the community.

Assessment or CSSP

Upload Assessment or CSSP

Upload supported file (Max 15MB)

Upload Proof of Disability (not required if submitting CSSP)

Upload supported file (Max 15MB)

Upload Person-Centered Plan (not required if submitting CSSP)

Upload supported file (Max 15MB)

Does Client have a current housing stabilization services provider?

Yes

Would Case Manager/Housing Consultant like to be in attendance at intake meeting?

Yes

Referral Signature

Referral Date

Thank you for your referral! We will be in contact within three (3) business days.