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 Proof of Disability (not required if submitting CSSP)

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

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.