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Information Request and Referral

If you’d like to receive more detailed information or to create a referral for services, please fill out the form below.

Contact Info
Individual submitting referral*
- Self
- Case Manager
- Legal Guardian
Individual to contact regarding referral*
- Self
- Case Manager
- Legal Guardian
Case Manager Information
Name of Case Manager*
First Last
Email*
Phone
Client Information
Initials of Client
Email
Phone
Age
Gender Identity*
- Male
- Female
- Non-binary
Guardianship Status*
- Self
- Appointed
Name
First Last
Type of Guardian
Funding*
- Waiver
- Medical Assistance
- Group Residential Housing
- Private Pay
- Other
Waiver Type
If other, please specify*
Program Info
I am interested in*
- Residential Programs
- Independence Programs
Residential Programs
County of Preference (Check all that apply)
Adult Foster Care
- Hennepin County
- Chisago County
- Carver County
- Wright County
Staffing Needs
Type of staffing required
- 1:1
- Awake Overnight
- Sleep Overnight
- Alone time home/community
(Daily) Hours of 1:1 requested
Hours of alone time in the home:
With Housemates
Without Housemates
Hours of alone time in the community:
With Housemates
Without Housemates
Independence Programs
Requested services*
- Individualized Home Supports w/ Training
- Supported Employment Services
- Individualized Home Supports w/ Family Training
- Homemaker Services
- Ryan White Services
- Individualized Home Supports w/o Training
- Respite Services
Goals/Outcomes for Services
I have a current caregiver that I would like Pinnacle to hire.
- Yes
- No
Number of hours per week*
Preferred day of week*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
- Flexible
Times available on Monday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Tuesday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Wednesday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Thursday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Friday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Saturday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available on Sunday
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Times available
- Morning (6am-11am)
- Afternoon (11am-5pm)
- Evening (5pm-10pm)
- Flexible
Personal Info
Current living arrangements
If seeking alternative housing, why?
Requested Start Date
Accessibility
- Wheelchair
- Adapted equipment
- Lifts
- Ambulatory
Comments about accessibility needs
Behavioral/Mental Concerns
- Self Injurious Behaviors
- Aggressive/Violent Behavior
- Drug/Alcohol Abuse
- Criminal History
- Felony
- Other
Comments about behavioral/mental concerns
Personal Care
- AM/PM Cares
- Dressing
- Transferring
- Bathing/Showering
- Feeding
Comments about personal care
Medical Issues/Diagnoses
- Wound Care
- Injections
- Med Administration
- Seizures
- Med Set-Up
- Med Reminders
- Diabetic Needs
- Other
If other, please specify
What are your diabetic needs?
Comments about medical issues/diagnoses
Transportation
- Medical
- Socialization
- Access to own transportation
- School/Day Program
Comments about transportation
Person Centered Planning Outcomes/Goals
Caregiver Preferences/Other Notes

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