• Mon to Fri: 9:00am to 5:00pm

  • 651-528-7141

  • ...

  • 2056 Woodlane Drive Woodbury MN 55125

METROCARESERVICES

HSS Referal Form

HOUSING STABILIZATION SERVICES REFERRAL FORM

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

Referral Date:
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Your First Name
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Your Middle Initial
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Your Last Name
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Your Date Of Birth
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Gender
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Race:
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SSN:
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Your Address
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City
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Zipcode
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Primary Emergency Contact Information

Your First Name
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Your Last Name
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Best Contact Number:
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Relationship:
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Special Needs

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

Does this person have a criminal background?
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Are you aware of any drug/ alcohol use?
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Does this person use the following? (mark all that apply)
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Does this person have an income source?
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(If yes, enter information below)

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

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

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Your First Name
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Your Last Name
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Your Address
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Zipcode
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City
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Best Contact Number:
Phonenumber
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Fax Number:
Fax Number:
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Email:
E-mail Address
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Waiver Case Manager Information

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

Opening Hours Monday to Friday 9am - 5pm

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

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