Date of application: Click or tap to enter a date.

Instructions: It is important that you complete this form in its entirety. If information is unknown or does not apply to the individual, please fill in the applicable fields with unknown or N/A. Do not leave any blank fields. If you have any questions, please contact Shelli Schultz at 763-331-8253.

Please fax completed form to: 763-331-9951 or submit to shellis@grandmasplaceinc.com

PERSONAL INFORMATION (applicant should fill out this area, may use assistance)
First Name:	Last Name:	Middle Initial:
Current Residence:
Address:
City:	State:	Zip:
Date of Birth:	Age:	☐ Male ☐ Female ☐ Other	Primary Language Spoken:
Daytime Contact Phone Number:	Evening Contact Phone Number:
Do you have a driver’s license?	☐ Yes ☐ No
Do you own a vehicle?	☐ Yes ☐ No
Do you have any pets?	☐ Yes ☐ No	If yes, is this pet a certified/registered therapy pet?	☐ Yes ☐ No
Do you have a Guardian? ☐ Yes ☐ No	Conservator? ☐ Yes ☐ No	Power of Attorney ☐ Yes ☐ No
Guardian/Conservator/Power of Attorney:	Name:	Phone #:
CADI/BI Waiver Case Manager:	Name:	Phone #:
Person to receive status of application:	Name:	Phone #:
There is No-Smoking allowed in the buildings. Are you okay with NOT smoking indoors?	☐ Yes ☐ No

Referral Information
Person making referral:
Waiver Case Manager:
Phone #	E-mail:

Location Desired: Grandma’s Place is the service provider; however, we have relationships with property managers at three locations. Which location is desired.

☐ 1900 Vincent Ave. Minneapolis – (Efficiency, 1 & 2 bedrooms)
☐ Virginian Court at 5910 West Broadway, Crystal – (1 & 2 bedrooms)
☐ Crystal Court at 6001 Bass Lake Road, Crystal - (1 & 2 bedrooms)
Mental Health Data
Have you been diagnosed with a mental illness? ☐ Yes ☐ No (If yes, complete the following questions)
What is your diagnosis?	Primary:	Secondary:
Others:
Are you on a JARVIS or Commitment? ☐ Yes ☐ No	If yes, which one?
Case manager:	Phone#:

Chemical Health Data
Have you been diagnosed or treated for Chemical Dependency? ☐ Yes ☐ No (If yes, complete the following questions)
Have you been in treatment in the last year?	☐ Yes ☐ No
If yes, where:	Discharge date:
Current supports (i.e. AA, NA, drop-in center)

Medical Health Data (Include copy of medication list) Keep in mind, we are not wheelchair accessible at this time.
What is your medical diagnosis?
Do you have any physical limitations or disabilities?	☐ Yes ☐ No	If yes, explain:
Do you need a physical assist to transfer	☐ Yes ☐ No
Do you need assistance with ADL’s?	☐ Yes ☐ No
Can you safely navigate stairs without a device?	☐ Yes ☐ No
Do you require handicap accessible living?	☐ Yes ☐ No
If you are diabetic, are you able to check your own blood sugar and administer your own insulin?	☐ Yes ☐ No ☐ N/A

Functional Information
Functional Information: Recent history (check all that apply over the past 12 months):	☐	Self-Injurious Behaviors
☐	Physical Aggression
☐	Verbal Aggression
☐	Mental Illness – Hospitalizations
☐	Sexual Coercion or Aggression
☐	Medication Non-Compliance
☐	Drug/Alcohol Abuse
☐	Suicidal Ideation and/or Attempt
☐	NONE OF THESE APPLY

Integrated Community Supports Services Desired (check all that apply)
Estimated # of hours per week
☐	Housekeeping assistance
☐	Laundry assistance
☐	Shopping support
☐	Medication monitoring and setups
☐	Mental Health management
☐	Money management & benefit coordination
☐	Community participation
☐	Support finding work or volunteering in the community or going back to school
☐	Non-medical and medical transportation coordination
☐	Appointment and provider coordination
☐	Menu planning and food prep support
☐	Personal hygiene, dressing, and bathing prompts/reminders
☐	Additional needs:
☐	Are you okay allowing staff to work with you in your apartment on the above services? ☐ Yes ☐ No
☐	Submit MN Choice Assessment
☐	Submit CSSP

Criminal History (answering yes, will not necessarily disqualify you)
Have you ever been arrested? ☐ Yes ☐ No	Have you ever been convicted of a crime? ☐ Yes ☐ No
If yes, please state if it was a misdemeanor or a felony.
Are you currently on probation?	☐ Yes ☐ No
If yes, Parole Officer’s name and phone#
Reason for probation or parole?
What are the probation requirements (if any)

Please list any arrest history, beginning with the most recent:

Arrest Date	Charge	Outcome of Charges

Financial Data
County of financial responsibility:
Do you receive Medical Assistance?	☐ Yes ☐ No	MA Number:	MA renewal date:
What type of waiver does the applicant have?	☐	BI	☐	CADI
☐	Applicant wishes to private pay
☐	Waiver pending – Assessment Date:
Do you currently have a spend down?	☐ Yes ☐ No	If yes, what is the monthly amount?
Do you have any current garnishments?	☐ Yes ☐ No	If yes, what is the monthly amount?
Any additional financial responsibilities?	☐ Yes ☐ No	If yes, what is the monthly amount?
Do you have a rep-payee?	☐ Yes ☐ No	If yes, name:	Phone#:
May we contact your payee for the purpose of discussing your financial situation and to verify income sources?	☐ Yes ☐ No
Do you currently manage your own finances?	☐ Yes ☐ No
Currently the applicant receives the monthly amount of (check all that apply and submit proof)	☐	SSI	$
☐	RSDI	$
☐	Income from a job	$
☐	Housing Supports	$
☐	Housing Voucher	$
☐	Other:	$

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Placement History (Where or with whom have you lived in the last four years. Include In or Outpatient sites, Family, IRTS and residential placements.)
Current Place:	Move-in date:	Date moved out:
Contact Name:	Email:
Address:	Phone:
Was rent paid on-time: ☐ Yes ☐ No	Number of late payments:	Lease violations: ☐ Yes ☐ No	How many?
Complaints by others:
Reason for leaving:
Place:	Move-in date:	Date moved out:
Contact Name:	Email:
Address:	Phone:
Was rent paid on-time: ☐ Yes ☐ No	Number of late payments:	Lease violations: ☐ Yes ☐ No	How many?
Complaints by others:
Reason for leaving:
Place:	Move-in date:	Date moved out:
Contact Name:	Email:
Address:	Phone:
Was rent paid on-time: ☐ Yes ☐ No	Number of late payments:	Lease violations: ☐ Yes ☐ No	How many?
Complaints by others:
Reason for leaving:

Do you owe any money to any of your previous residences? ☐ Yes ☐ No

If yes, please explain:

Does your current placement require any kind of notice? ☐ Yes ☐ No

If yes, please explain:

What is your desired move-in date?

Authorization to Obtain or Release Records
Applicants Name:	Phone:
Date of birth:
Street Address:
City:	State:	Zip:
Guardian Name:	Phone #:

I may cancel this authorization in writing at any time by contacting Grandma’s Place 763-250-2500.

This authorization is valid for one year after the date I sign it.

A copy of this authorization is as valid as the original.

This information may be disclosed to other parties who are entitled to it by law and therefore no longer protected under the privacy rule.

I understand the information included in this form and communication, both verbal and written that is shared with Grandma’s Place prior to an official intake meeting will be used solely to assess and coordinate services.

I Authorize: Grandma’s Place to obtain records about me.

To communicate both verbally and in writing with the professionals and family listed below. (Check all that apply)

☐	Waiver Case Mgr.
Waiver Case Manager:	Agency:
Phone #:	E-Mail address:
☐	Behavioral Case Mgr.
Behavioral Case Mgr.:	Agency:
Phone #:	E-Mail address:
☐	Other
Other:	Agency:
Phone #:	E-Mail address:

By signing below, I certify that the information included in this form is correct to the best of my knowledge.
Name and relationship of person completing this form:
Printed Name	Relationship to Applicant
Signature	Date
Applicant:
Signature	Date
Other Individual(s) Assisting with the completion of this form:
Printed Name	Relationship to Applicant
Signature	Date
Printed Name	Relationship to Applicant
Signature	Date

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Informed Consent Release of Criminal History Data Please print legibly – Use complete name including middle name

Last Name _________________________ First Name ___________________ Middle Name ______________ Maiden or Former Name(s) __________________________________________________________________ Date of Birth _______________________	Sex (M) or (F) Social Security Number _______________________ Driver’s License Number _____________________________ Issuing State ____________________________ Current Address ___________________________________________________________________________ City, State, Zip Code ________________________________________________________________________

I hereby authorize and grant my informed consent to the Minnesota Bureau of Criminal Apprehension to release to Grandma’s Place, Inc. any information contained about me in the Minnesota Computerized Criminal History for housing with services with this agency. I hereby release the Minnesota Bureau of Criminal Apprehension and Grandma’s Place, Inc. from all actions and causes of action, of any kind and nature whatsoever, past, present and future, arising out of the release of information obtained with this consent. This authorization shall be valid for a period of twelve (12) months from the date of signature.

Informed Consent Release of Predatroy Offender Registration

Please print legibly – Use complete name including middle name

Signature	Date