Resources – Prosperity Wellness

612-433-5081
info@prosperitywellness.org

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Referral Form

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Download the Referral Form, fill in the form, save form and upload through the below form.

Name

Upload Referral Form

CLIENT INFORMATION

Full Name

DOB

Sex

Male Female

Address

City

State

ZIP

Phone

MA/PMI #

Start Date

Documented Disability

SSI/SSDI Developmental Disability Physical Illness Learning Disability Mental Illness Chemical Dependency

Proof of disability (check the included document)

Professional Statement of Need (DHS-7122) Coordinated Services and Supports Plan (CSSP) Care Plan

Current Living Situation (please check appropriate box)

Own housing

Lease/Rent Other

Service Provider

Foster care Group Home Emergency Shelter Jail/prison/juvenile detention Hospital/Treatment/Detox/Nursing Home Family/friends due to economic hardship Hotel/Motel Place not meant for housing

Are Medical Assistance and the waiver currently active?

Yes No

Renewal date

Select Services Type

Housing Transition Housing Sustaining Housing Consultation

Insurance

Medica Health Partners UCare Hennepin Health United Healthcare MA SouthCountry Other

Other Insurance

Current Level of Housing Instability (please check appropriate box)

Homeless At-Risk of Homelessness Transitioning from Facility Institution Level of Care/Eligible for Waiver

Please fill out the form with as much detail as possible and return with a copy of the most current proof of disability document. Email referral to Info@prosperitywellness.org Phone: 612-433-5081 or 612-250-4819

Guardianship Status

Self Other (list name & contact info)

Other Guardianship Status

CASE MANAGER INFORMATION

Prosperity Wellness values the presence, support, and input of case managers on the support team. Please fill this form below

Case Manager Name

Phone #

County/Agency

Fax #

Address

City

State

Zip

Everybody we assist deserves a better life, and that is what drives us. Do you have questions about our services? Please let us know and contact us.

Get More Details

Contact Information

612-433-5081
info@prosperitywellness.org
13310 Cedar Ave Apple Valley, MN 55124

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