651-774-0011

Long-Term Residential Services Referral Form

"*" indicates required fields

Long Term Residential Referral Form

Referent Information

Name of Person Completing This Form*
(e.g., provider, agency, counselor, parent/guardian, case manager, self)

Client Information

Client Name*
Client Gender
Screening Documents

Eligibility Criteria

What staffing patterns are required?
*Please note: People Incorporated staff do not assist in ADLs such as transfers, bathing, toileting, dressing, or feeding.
Check all that apply
Name of CADI Waiver Case Manager*

Guardianship Information

Legal Guardian?

Legal Information

Criminal history?
*Background checks are required in some of our residential settings.
Active warrants?
Sexual offenses?
*Please note, programs can only accommodate level 1 offenses.
Is the client under commitment?

Financial Information

Does your client currently have a representative payee?

Program Information

What program would be a good match for your client?
Location Preference (check all client would be interested in)
Please select any of the following People Incorporated services that you may be interested in: