Name * First Name Last Name Phone * (###) ### #### Email * Address PMI Number * Do you have a case manager Yes No Do you receive medical assistance Yes No Are you 18 Years or Older? Yes No Have a documented disability or disabling condition, defined as one of the following: A person who is aged, blind or has a disability as described under Title Il of the Social Security Act. A person with an injury or illness that is expected to cause extended or long-term incapacitation. A person with a developmental disability (or related condition) or mental illness. A person with a mental health condition, substance use disorder or physical injury that required a residential level of care and who is now in the process of transitioning to the community. A person with a substance use disorder and is enrolled in a treatment program or is on a waiting list for a treatment program. Are you experiencing housing instability, evidenced by one of the following risk factors: Homeless. An individual or family is considered homeless when they lack a fixed, adequate nighttime residence. Currently transitioning, or has recently transitioned, from an institution or licensed or registered setting (registered housing with services facility, board and lodge, boarding care, adult foster care or community residential setting, hospital, Intermediate Care Facility for persons with Developmental Disabilities (ICF/DD), intensive residential treatment services, any MN hospitals. Are you at risk of homelessness? An individual or family is at risk of homelessness. At risk of institutionalization - meets an institutional level of care/eligible for the following waivers. Referral, Company, or Organization Name: Thank you!