HSS Referral Use this form to submit an HSS referral. Our team will get back to you shortly. Thank you! Is This a Self Referral? * Yes No Client Name * First Name Last Name Client Address * Client Email Client Phone Number * (###) ### #### Client Date of Birth MM DD YYYY Client PMI (If Known) Client Gender Does the client receive medical assistance? Yes No If so, through which medical insurance provider? Ucare Health Partners Blue Cross Blue Shield Medica Hennepin Health United Healthcare MA Other Does the client need help with transitioning (finding a home) or sustaining their housing? Transitioning Sustaining Both What is the client's current living situation? Own housing Lease Mortgage Roommate Family/friends due to economic hardship Service provider Foster care Group home Hospital/Treatment/Detox/Nursing home Jail/Prison/Juvenil Detention Hotel/Motel Emergency shelter Place not meant for housing Others Does the client have a PSN? (Professional Statement of Need) Yes No Does the client have a CADI waiver Yes No - - - - - - - - - - - - - - - Only complete the fields below if you are making a referral on behalf of a client - - - - - - - - - - - - - - - - - - - - . Referrer's Name First Name Last Name Referrer's Phone (###) ### #### Referrer's Email Referrer's Organization & Job Title We’ve received your referral. You will hear from our team soon!
