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REFERRAL FORM

We welcome referrals from the community. Please fill out the form below.
Client First Name
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Client Last Name
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Your E-mail Address
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Your Phonenumber
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Your Address
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City
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Minnesota
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Zipcode
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What city is the applicant interested in applying to *
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Gender:
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If other, please enter gender below
If other, please enter gender below
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List all present medical diagnosis (Please keep in mind we are not wheelchair accessible at this time)
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What is the applicants current living situation ?
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If other living situation, enter below:
Other Living Situation
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Is the applicant currently pregnant?
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If Yes to above question, when is your due date?
Select a date
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Does the applicant any pets?
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Does the applicant have a drivers license?
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Does the applicant own their own vehicle?
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Does the applicant plan to have a roommate?
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This completes Part A of the application, press \"Next\" to continue.
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Part B: Legal Background

Please note, answering Yes will not necessarily disqualify you
Has the applicant ever been arrested?
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Has the applicant ever been convicted of a crime?
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If Yes to the above, please state if it was a misdemeanor or felony. Describe and include dares and status of cases.
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Is the applicant currently on probation?
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If Yes to the above, please enter name & phone number of probation officer
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Is applicant currently on parole?
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If Yes to the above, please enter name & phone number of parole officer
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What are the applicants probation requirements if any?
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This completes Part B of the application, press \"Next\" to continue.
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Part C: Financial

Please provide the most accurate information to the best of your knowledge.
What type of waiver does the applicant have?
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If other, please enter Waiver
If other, please enter Waiver
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Primary income sources (Check all that apply)
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If other, please enter Income Source
If other, please enter Income Source
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What is the applicants total monthly income from all sources?
Enter only numbers, not symbols like $
ex: 100
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Does the applicant have any spend downs or garnishments? If so - please detail.
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Financial management (check all that apply)
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If other, please enter other financial management
If other, please enter financial management
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This completes Part C of the application, press \"Next\" to continue.
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Part D: Referral Information

Please provide below information or attach county referral form
How immediate is placement needed? If less than 4 weeks, why?
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Name of person making referral
Full Name
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Relationship to applicant
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Living arrangement sought
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If other, please enter other living arrangement sought
If other, please enter living arrangement sought
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Case Manager Name
Enter Full Name
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Case Manager Email
example@example.com
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Case Manager Phone
Please enter a valid phone number.
Phonenumber
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This completes Part D of the application, press \"Next\" to continue.
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Part E: Placement History

Please detail where or with whom the applicant has lived in the last 4 years. Include out patient sites, family IRTS and residential placements.

Location #1

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
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If Other, please enter living situation
If Other, please enter living situation
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From
date started living at location/date started being homeless
Select a date
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Until
date stopped living at location/date stopped being homeless
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Location address is:
Street Address
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City
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  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • 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
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • 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 -
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Zipcode
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Contact Email Address
Reference Email Address
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Contact Phone:
Reference Phonenumber
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Location #2

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
Field is required!
Field is required!
If Other, please enter living situation
If Other, please enter living situation
Field is required!
Field is required!
From
date started living at location/date started being homeless
Select a date
Field is required!
Field is required!
Until
date stopped living at location/date stopped being homeless
Select a date
Field is required!
Field is required!
Location address is:
Street Address
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Field is required!
City
Field is required!
Field is required!
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • 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
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • 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 -
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Field is required!
Zipcode
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Field is required!
Contact Email Address
Reference Email Address
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Field is required!
Contact Phone:
Reference Phonenumber
Invalid phonenumber!
Invalid phonenumber!

Location #3

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
Field is required!
Field is required!
If Other, please enter living situation
If Other, please enter living situation
Field is required!
Field is required!
From
date started living at location/date started being homeless
Select a date
Field is required!
Field is required!
Until
date stopped living at location/date stopped being homeless
Select a date
Field is required!
Field is required!
Location address is:
Street Address
Field is required!
Field is required!
City
Field is required!
Field is required!
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • 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
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • 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
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Field is required!
Contact Email Address
Reference Email Address
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Field is required!
Contact Phone:
Reference Phonenumber
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Invalid phonenumber!
Has the applicant been evicted within the last 12 months?
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Has the applicant had an involuntary service termination within the past 12 months?
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This completes Part E of the application, press "Next" to continue.
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Part F: Functional Information

Please provide information relating to the last 12 months.
For any of the following questions, if your answer is No - simply enter "Unknown" or "N/A" If Yes, please explain.
Does the applicant have a history of recurrent violent behaviours in the last 12 months? (Examples include Physical Aggression, Agitation, Verbal Aggression, Sexual Coercion or Aggression).
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Does the applicant have a history of drug or alcohol use in the past 12 months?
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Does the applicant have a history of Self injurious behaviors or Suicidal Ideation and/or Attempt within the last 12 months?
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Does the applicant have a history of property destruction within the last 3 years?
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Does the applicant have ability to safely utilize appliances (Gas stove, Electric stove, Microwave)
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Has the applicant been hospitalized in the past 12 months?
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Has the applicant had any falls in the past year?
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Does the applicant have a history of Medication Non-Compliance in the past 12 months?
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Has the applicant had any MAARC reports in the past 12 months?
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Are there any other safety or behavioural concerns to consider for this applicant?
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Upload your files

Please upload relevant files to support your application including CSSP, MN Choices Assessment, Face Sheet etc...
Upload your documents...
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Declaration

By signing below, I certify that the information included in this form is correct to the best of my knowledge.
Name of person completing this form:
Full Name
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Relationship to applicant:
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Signature:
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Sign Date:
MM-DD-YYYY
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Awesome! This completes your application. The next step is to sign the release of information so that we can begin to process your application.
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Release of Information Authorization

Please read and sign the following so that we can begin to process your application.
I have reviewed the Notice of Use and Disclosure Practices.

I understand that the requested Protected Health Information, criminal background information, and rental history will be used by Alliance Care for the purpose of home health care.

I hereby authorize verbal and written communication from Alliance Care and in addition, agree to release:


The following portions of my clinical record

History and Physical
Discharge Summary
Consults
Plans of Care
Current/ Past Progress Notes
CSSP
MNchoice Assessment
Mental Health Records
Chemical Dependency Records
Operative Reports
Health Care Directives
Medication List (including Pharmacy Communication)
Physician's Orders
Flow Sheets
POLST (Health Care Directive)
Medical/Health information


And the following portions of other records to Alliance Care including:

Criminal Background Check via BCA or other sources
Rental History Verifications within the last 5 years
Case Management Records
Please read through the declaration below and sign and date at the bottom.
I understand that the records will be used to continue evaluation or treatment, coordinate services, and determine eligibility for services.


I understand that my records are protected by data privacy regulations. Alcohol and drug abuse records may be protected by Federal Law (42 CFR Part 2). These records cannot be released without my consent unless specifically directed by law.


I understand that I have the right to refuse to sign this consent.


I understand that I may withdraw or revoke this consent at any time if the action it authorizes has not been carried out.


I understand that this consent expires one year from the date I signed it.


A copy of this authorization shall be considered as effective and valid as the original.
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Resident / Resident Representative Full Name
Full Name
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Relationship to resident
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Signature:
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Sign on:
MM-DD-YYYY
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Awesome! This completes your application. The next step is to sign the release of information so that we can begin to process your application.
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