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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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Information Request and Referral

Contact Info

Case Manager Information

Client Information

Program Info

Residential Programs

County of Preference (Check all that apply)

Staffing Needs

Hours of alone time in the home:

Hours of alone time in the community:

Independence Programs

Personal Info