Referral Application

Your Progress To Complete

This form contains 6 sections and will take around 10-15 minutes to complete. If at any time you need to save your progress to complete later, simply click “Save” at the bottom and you can finish off where you started. It is important that you complete this form in its entirety. If information is unknown or does not apply to the individual please fill in the applicable field with unknown or N/A. Do not leave any blank fields. Providing false or misleading information on this application or during the screening process is an automatic disqualifier. We will be gathering information about the following, so please gather all relevant resources to ensure you can complete the application to the best of your ability.

Part A: Applicant Personal Information

Part B: Legal Background

Part C: Financial Information

Part D: Referral Information

Part E: Past residence / placement information

Part F: Functional information

Upload: Supporting documents including CSSP, MN Choices Assessment, Face Sheet, etc…

These documents will be required upon acceptance into Vital Home Services programs. If you have any questions please call the our Vital Home Services office Today.

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Legal Background

Has the applicant ever been arrested?*

Yes

Has the applicant ever been convicted of a crime?*

Yes

please state if it was a misdemeanor or felony Describe and include dares and status of cases. *

Is the applicant currently on probation?*

Yes

please enter name & phone number of probation officer *

Is applicant currently on parole?*

Yes

please enter name & phone number of parole officer*

What are the applicants probation requirements if any?*

Referral Information

How immediate is placement needed? If less than 4 weeks, why? *

Write Here

Name of person making referral

First Name *

Last Name*

Relationship to applicant*

Write Here

Living arrangement sought*

ICS Appartment

Waiver Services

Other

Case Manager Name

Fist Name*

Fist Name

Last Name*

Last Name

Case Manager Email*

Email Address

Case Manager Phone*

Phone

Placement History

Location #1*

Write Here

Location #2*

Write Here

Location #3*

Write Here

Has the applicant been evicted within the last 12 months?*

Yes

Has the applicant had an involuntary service termination within the past 12 months?*

Yes

Functional Information

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).*

Write Here

Does the applicant have a history of drug or alcohol use in the past 12 months?*

Write Here

Does the applicant have a history of Self injurious behaviors or Suicidal Ideation and/or Attempt within the last 12 months?*

Write Here

Does the applicant have a history of property destruction within the last 3 years?*

Write Here

Does the applicant have ability to safely utilize appliances (Gas stove, Electric stove, Microwave)*

Write Here

Has the applicant been hospitalized in the past 12 months?*

Write Here

Has the applicant had any falls in the past year?*

Write Here

Does the applicant have a history of Medication Non-Compliance in the past 12 months?*

Write Here

Has the applicant had any MAARC reports in the past 12 months? *

Write Here

Are there any other safety or behavioural concerns to consider for this applicant? *

Write Here

Upload your files

Drag 'n Drop files here

Max file size: 976.56 KB. | Allowed file types: gif,jpeg,png,jpg

Select Files

By signing below, I certify that the information included in this form is correct to the best of my knowledge.*

Write Here

Name of person completing this form:

First Name *

Name

Last Name *

Name

Relationship to applicant*

Write Here

Date Time Title*

Select Date ×

Great! This completes your application. The next step is to sign the release of information so that we can begin to process your application.

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 Vital Home Services for the purpose of home health care. I hereby authorize verbal and written communication from Vital Home Services 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 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) Laboratory Results (All) Radiology Reports (All) And the following portions of other records to Affinity Residential 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.

Resident/ Resident Representative Full Name:

First Name

Last Name

Relationship to resident*

Write Here

Signed on*

Write Here

Get In Touch With Us

Our clients lead fulfilling and independent lives within the comfort of their homes. Ready to start a new journey of life contact us.