METROCARESERVICES

FORMS

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HOUSING STABILIZATION SERVICES REFERRAL FORM

*Referral Form must be completed in full before MCHS can process referral*

Referral Date:
Select a date
Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Middle Initial
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Date Of Birth
Field is required!
Field is required!
Gender
Field is required!
Field is required!
Race:
Field is required!
Field is required!
SSN:
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!

Primary Emergency Contact Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Best Contact Number:
Invalid phonenumber!
Invalid phonenumber!
Relationship:
Field is required!
Field is required!

Special Needs

Are there any known cultural consideration needs?
Field is required!
Field is required!
Is there any gender preference regarding the assigned staff?
Field is required!
Field is required!
specify:
Field is required!
Field is required!
If yes:
Field is required!
Field is required!
Allergies:
Field is required!
Field is required!
Other (be specific):
Field is required!
Field is required!
Diagnostic Code and Description (mental health and physical health):
Field is required!
Field is required!
PMI Number (MA only):
Field is required!
Field is required!

Level of Need

Does this person have a criminal background?
Field is required!
Field is required!
Are you aware of any drug/ alcohol use?
Field is required!
Field is required!
Does this person use the following? (mark all that apply)
Field is required!
Field is required!
Does this person have an income source?
Field is required!
Field is required!

(If yes, enter information below)

Type of income:
Field is required!
Field is required!
Amount
Enter the Amount
Field is required!
Field is required!
Type of income:
Field is required!
Field is required!
Amount
Enter the Amount
Field is required!
Field is required!
Type of income:
Field is required!
Field is required!
Amount
Enter the Amount
Field is required!
Field is required!
Type of income:
Field is required!
Field is required!
Amount
Enter the Amount
Field is required!
Field is required!
Does this person currently have a lease?
Field is required!
Field is required!
If so, when will it end?
Field is required!
Field is required!
Is this person currently homeless or will be homeless?
Field is required!
Field is required!
If so, when?
Field is required!
Field is required!
How soon does this person want to move? (exact date not necessary)
Field is required!
Field is required!
How soon does this person want to move? (exact date not necessary)
Field is required!
Field is required!
Is this person best described as actively looking for housing or passively looking for housing?
Field is required!
Field is required!
Other important notes (please be specific):
Field is required!
Field is required!

Care Preferences

How many days per week does the Case Manager want us to provide HSS Services to this person?
Field is required!
Field is required!
How many units per week does the Case Manager expect to be used for this person?
Units
-
+
Field is required!
Field is required!
Housing search preferences (mark all that apply):
Field is required!
Field is required!
Will this person need Transitional Services? (choose all that apply)
Field is required!
Field is required!

Legal Status & Legal Representative Contact Information

Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
City
Field is required!
Field is required!
Best Contact Number:
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Fax Number:
Fax Number:
Field is required!
Field is required!
Email:
E-mail Address
Field is required!
Field is required!

Waiver Case Manager Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Office Fax
Field is required!
Field is required!
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Agency Name:
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

PLEASE BE ADVISED: If this person fails to respond to MCHS HSS Specialists on 3 or more occasions in a month, a 30-day termination notice will be served.

At time of referral, you may submit any other supporting documents (if you have them available):

*Most current Diagnostic Assessment *Copy of Functional Assessment / LOCUS *County Case Plan *Crisis Plan *etc.
Case Manager Signature:
Field is required!
Field is required!
Date:
Select a date
Field is required!
Field is required!
Submit

Referrals and copies of documents can be mailed, faxed, or e-mailed to:

METRO CARE HUMAN SERVICES 6043 HUDSON ROAD, SUITE 340 WOODBURY, MN 55125 Fax: (651) 528-7897 Attn: Gao Vang

E-mail: info.intake@metrocareservicesmn.com Subject: HAC Referral Form

TRANSITIONAL SERVICES REFERRAL FORM

Recipient’s Name:
  • First choice
  • Second choice
  • Third choice
Field is required!
Field is required!
Date:
Select a date
Field is required!
Field is required!

Client Information

First Name
Field is required!
Field is required!
Middle Initial
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Gender:
Field is required!
Field is required!
Race:
Field is required!
Field is required!
SSN:
Field is required!
Field is required!
Amount
Field is required!
Field is required!
Diagnostic Codes and Descriptions:
Diagnostic Codes and Descriptions:
Field is required!
Field is required!
PMI #:
Field is required!
Field is required!
Phone Number:
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Cell Number:
Cell Number:
Invalid phonenumber!
Invalid phonenumber!
Email:
E-mail Address
Field is required!
Field is required!

Contacts (please fill out all contact information)

Case Manager full name:
Field is required!
Field is required!
Best Contact Number:
num
Invalid phonenumber!
Invalid phonenumber!
E-mail:
Field is required!
Field is required!
Case Manager Supervisor full name:
Field is required!
Field is required!
Best Contact Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Email:
Field is required!
Field is required!
Relocation Service Coordinator full name:
Field is required!
Field is required!
Best Contact Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
E-mail:
Field is required!
Field is required!
Care Coordinator full name:
Field is required!
Field is required!
Best Contact Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
E-mail:
Field is required!
Field is required!
Payments Source:
Field is required!
Field is required!
Service Provider:
Field is required!
Field is required!

Current Address (Complete only if movers need to pick up belongings)

Address and Unit Number:
Field is required!
Field is required!
City
Field is required!
Field is required!
Zip code:
Field is required!
Field is required!

Storage Facility (Complete only if movers need to pick up items)

Facility Name:
Field is required!
Field is required!
Unit:
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!

New Address

Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Move Date:
Select a date
Field is required!
Field is required!

Transitional Services Information

Community Support Plan (CSP) authorized Services***: (mark all that apply)
Field is required!
Field is required!

***Please note all lines MUST be authorized prior to providing services. MCHS requires a Service Agreement screenshot prior to providing any services.

Apartment Size:
Field is required!
Field is required!
Color Preference (may not be available)
Field is required!
Field is required!

(T2038) Moving Expenses/ Damage Deposit/ Application Fee:

Damage Deposit (Damage deposit cannot exceed $500.00 and will not be available until day of move. Letters guaranteeing payment will be sent out prior to move.)
Field is required!
Field is required!
Application Fee (Application fee cannot exceed $50.00 and will not be available until day of move. Letters guaranteeing payment will be sent out prior to move.)
Field is required!
Field is required!
Amount
Field is required!
Field is required!

Payment Details

Name Payable To:
Field is required!
Field is required!
Phone Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Billing Address:
Field is required!
Field is required!
City
Field is required!
Field is required!
  • - select a state -
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  • Alaska
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  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
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  • Nevada
  • New Hampshire
  • New Jersey
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  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
(T2038-U1) Essential Furniture: (not to exceed $1,000) (Only check items needed) If all items are checked, individual will receive some used furniture.
Field is required!
Field is required!

*Twin Bed, unless body size deems otherwise

Submit

Internal Referral Form

Referral Source Information

Person Making Referral:
Full Name
Field is required!
Field is required!
Date:
Select a date
Field is required!
Field is required!
Referral Organization:
Field is required!
Field is required!
Phone #:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Office Contact Person:
Field is required!
Field is required!
Fax #:
Field is required!
Field is required!

Personal Information

Your First Name
Field is required!
Field is required!
Your Middle Initial
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Gender
Field is required!
Field is required!
Race
Field is required!
Field is required!
SSN
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Phone Number
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Cell Number
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
E-mail address
Your E-mail Address
Field is required!
Field is required!
Reason for Referral request
Type Here
Field is required!
Field is required!

Client referred for: (check one or more boxes below)

Field is required!
Field is required!
Do you have a Current SUD or Rule 25 Assessment ( within the last 30 days)
Field is required!
Field is required!
Previous Assessments
Field is required!
Field is required!
Where/When
Field is required!
Field is required!
Previous Treatments?
Field is required!
Field is required!
Where/When
Field is required!
Field is required!

Funding: Insurance

Primary insurance: (please check box)
Field is required!
Field is required!
PMI Number
PMI Number
Field is required!
Field is required!
Medical Assistance Number
Medical Assistance Number:
Field is required!
Field is required!
Primary Ins. #
Field is required!
Field is required!
Group #
Field is required!
Field is required!
Other insurance information
Type Here
Field is required!
Field is required!
CCDTF(Rule 25 Funding)
Field is required!
Field is required!
County
County
Field is required!
Field is required!
Worker’s Name who approved
Worker's Name
Field is required!
Field is required!

Rule 25/Comprehensive Assessment

Previous Assessments dates/ company? Assessor /
Previous Assessments dates/ company? Assessor /
Field is required!
Field is required!
Name of Program/Person
Name of Program/Person
Field is required!
Field is required!

Referrals can be e-mailed to: Deb Hagen E-mail: deb.hagen@metrocareservicesmn.com Subject: Substance Abuse Referral

Submit

GENERAL REFERRAL FORM

Referral Date:
Select a date
Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Middle Initial
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Date Of Birth
Field is required!
Field is required!
Gender
Field is required!
Field is required!
Race:
Field is required!
Field is required!
SSN:
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Reason(s) for Referral
Field is required!
Field is required!
Diagnosis (mental health and physical health) (please include diagnostic code as well as description)
Type Here
Field is required!
Field is required!

Special Needs

Are there any known cultural consideration needs
Field is required!
Field is required!
specify:
Field is required!
Field is required!
Is there any gender preference regarding the assigned staff?
Field is required!
Field is required!
If yes:
Field is required!
Field is required!
Allergies:
Field is required!
Field is required!
Other (be specific):
Type Here
Field is required!
Field is required!

Insurance Information

Primary insurance: (please check box)
Field is required!
Field is required!
Other
Field is required!
Field is required!
PMI Number:
PMI Number
Field is required!
Field is required!
Medical Assistance Number:
Medical Assistance Number
Field is required!
Field is required!
Primary Ins. #
Field is required!
Field is required!
Group #
Field is required!
Field is required!
Other insurance information
Field is required!
Field is required!

Does this person have: (mark if known; leave blank if unknown)

Waiver Case Manager? (If yes, enter information below)
Field is required!
Field is required!
Waiver Type:
Field is required!
Field is required!
Mental Health Case Manager? (If yes, enter information below)
Field is required!
Field is required!
Care Coordinator with primary clinic or insurance company? (If yes, enter information below)
Field is required!
Field is required!
Other: (Please specify type of provider such as physician, therapist, psychiatrist, child protection worker, etc.)
Provider Type
Field is required!
Field is required!

Mental Health Case Manager Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number:
Office number
Invalid phonenumber!
Invalid phonenumber!
Office Fax:
Field is required!
Field is required!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Waiver Case Manager Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number
Office number
Invalid phonenumber!
Invalid phonenumber!
Office Fax
Field is required!
Field is required!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Care Coordinator Information

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Office number:
Field is required!
Field is required!
Office Fax:
Field is required!
Field is required!
Cell number:
Cell number
Invalid phonenumber!
Invalid phonenumber!
Agency Name
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

Legal Status & Legal Representative Contact Information

Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Fax Number
Field is required!
Field is required!
Email:
Field is required!
Field is required!

Primary Emergency Contact Information

First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Best Contact Number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Second Contact Number:
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Relationship:
Field is required!
Field is required!
Email:
E-mail Address
Field is required!
Field is required!

Case Manager/ Other Provider Type Contact Information/ Referral Source

First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!
Office number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Office Fax:
Field is required!
Field is required!
Office number:
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Agency Name:
Field is required!
Field is required!
Would you like to be updated on all assessment scheduling & treatment of services?
Field is required!
Field is required!

At time of referral, you may submit any other supporting documents (if you have them available): *Most current Diagnostic Assessment *Copy of Functional Assessment / LOCUS *County Case Plan *Crisis Plan *CSSP *IAPP *SMA

Referrals and copies of documents can be mailed, faxed, or e-mailed to: METRO CARE HUMAN SERVICES 6043 HUDSON ROAD, SUITE 340 WOODBURY, MN 55125 Fax: (651) 528-7897 Attn: Arnold Kubei E-mail: info.intake@metrocareservicesmn.com Subject: Referral Form

Submit

IRTS REFERRAL FORM

Referral Source Information

Name & Title
Field is required!
Field is required!
Agency
Field is required!
Field is required!
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
E-mail Address
Field is required!
Field is required!
Relationship to Client:
Field is required!
Field is required!

Client Information

Personal Information

First Name
Field is required!
Field is required!
Middle Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Preferred Name
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Sex Assigned at Birth:
Field is required!
Field is required!
Gender Identity:
Field is required!
Field is required!
Ethnic Identity:
Field is required!
Field is required!
Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
E-mail Address
Field is required!
Field is required!
SSN:
Field is required!
Field is required!

Legal Status & Legal Representative Contact Information

Field is required!
Field is required!
First Name
Field is required!
Field is required!
Last Name
Field is required!
Field is required!
Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Best Contact Number
Invalid phonenumber!
Invalid phonenumber!
Fax Number:
Field is required!
Field is required!
E-mail Address
Field is required!
Field is required!

REQUIRED

➢ If the client is under guardianship, the legal document indicating this must be included.
➢ If the client is under commitment, the pre-petition screening, psychological examination, and commitment order must be included.

Mental Health History

Mental Health Diagnoses:
Type Here
Field is required!
Field is required!
Check all that apply:
Field is required!
Field is required!
Describe concerns indicated above:
Type Here
Field is required!
Field is required!
Submit

Opening Hours Monday to Friday 9am - 5pm

Metro Care Human Services provides a variety of high quality mental health counseling including intervention, case management, advocacy.

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