Appendix_4_Housing_Search_Referral_Form.docx

Appendix 4

Referral Form for Housing Search Entity Services

Note on Form Purpose and Use

· This form is used by Case Managers to make a referral for Housing Search Entity services for an Individual enrolled in the Money Follows the Person (MFP) Demonstration grant, the Acquired Brain Injury (ABI)/Moving Forward Plan (MFP) Home and Community Based Services (HCBS) Waivers, or MRC state-funded programs. Completion and submission procedures may vary by contracting agency.

· It is submitted directly to a selected Housing Search Entity who will accept or decline the referral within two business days

Date Referral is Submitted: _______/______/__________

Program Participant

Program Name (e.g., ABI, MFP, DEMO)

Name:

Nursing Facility Address

Email and Phone

Person Making Referral

Name and Position

Office / Agency

Qualified Housing Search Entity Receiving Referral

Name:

Agency:

Program Participant Information:

If MFP DEMO, when person enrolled in MFP Demonstration

Month:

Day:

Year:

Age?

Anticipated monthly income after leaving facility (specify source)

Length of time since last lived in the community?

Number of bedrooms needed (include live-in PCA)

YES

NO

If YES, provide detail if available

Uses wheelchair or other specialized medical equipment or assistive technology?

Other accommodations needed?

Previously Homeless?

Has geographic preference?

Has legal guardian to assist in decision making?

Other known barriers to housing?

Revised 4/2023