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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
Our Services
I am interested in*
- Residential Programs
- Independence Programs
- Case Management/CFSS Consultation Services
Location (city) of Requested Services*
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
- Other
Name
First Last
Type of Guardian
Funding For Housing*
- GRH/Housing Support
- SSI
- Private Pay
Funding for Services*
- DD Waiver
- CADI Waiver
- Other
If other, please specify*
Residential Programs
County of Preference (Check all that apply)
- Hennepin County
- Chisago County
- Carver County
- Wright County
Staffing Needs
Type of staffing required
- 1:1
- Awake Overnight
- Sleep Overnight
- Alone time home/community
Hours of alone time in the home:
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
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?
Person Centered Planning Outcomes/Goals
Caregiver Preferences/Other Notes
Case Management/CFSS Consultation Services
Do you have case management service with Pinnacle Services?*
- Yes
- No
*If you have selected yes, please be aware that Pinnacle cannot be your CFSS Consultation provider due to CFSS Policies. You will need to seek another agency for CFSS Consultation.
Do you have a CFSS Consultation provider already?*
- Yes
- No
Who is your CFSS Consultation provider?*
Assessment Date*

Click or tap to enter a date
Are you okay with all meetings being completed virtually (no in-person meetings)?*
- Yes
- No
*If you have selected "No", please be aware that you will need to seek another provider as we are currently only providing virtual meetings.
Do you currently have services (PCA/CSG or waiver)?*
- Yes
- No
Do you know your service span?*
- Yes
- No
What is your Services Span?*
Do you have a current waiver case manager or Care Coordinator?*
- Yes
- No
If yes, what is their contact information (Name & phone # and email)?*
Are you in a managed care organization?*
- Yes
- No
Select the Managed Care Organization (MCO) you're a part of:
- Blue House
- HealthPartners
- Hennepin Health
- Itasca Medical Care
- Medica
- PrimeWest Health
- South Country Health Alliance (SCHA)
- UCare
Enter your Member ID#
General Information for Consultation Services participant:*
First Last
Date of Birth*
Primary Language*
Address and Contact Details:
Street Address Address Line 2 City State ZIP Code
Contact Preferences:*
- Mail
- Email
- Bulk email/newsletter
- Phone
Mail Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Contact Preferences: Preferred Time*

: HH

MM
Contact Preferences: Preferred Date*
Describe contact preferences*
Can we Contact the Participant Directly?*
- Yes
- No
If no, who should we contact?*
First Last
Their Email*
Their Phone*
Will they need an interpreter?*
- Yes
- No
For what Language?*

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