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Referral

NAFRIM GROUP SERVICES LLC HOUSING STABILIZATION SERVICES REFERRAL FORM

Download Referral Form

*Referral Form must be completed in full before NGS can process referral*

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Personal Information

Gender
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Primary Emergency Contact Information

Special Needs

Are there any known cultural consideration needs?
Is there any gender preference regarding the assigned staff?
If yes

Diagnostic Code and Description

(mental health and physical health)

Level of Need

Does this person have a criminal background?
Are you aware of any drug/ alcohol use?
Does this person use the following? (mark all that apply)
Does this person have an income source? (If yes, enter information below)
Does this person currently have a lease?
Is this person currently homeless or will be homeless?
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Care Preferences

How many days per week does the Case Manager want us to provide HSS Services to this person?
Housing search preferences (mark all that apply)
Will this person need Transitional Services? (choose all that apply)

Legal Status & Legal Representative Contact Information

Is this person currently homeless or will be homeless?

Waiver Case Manager Information

Would you like to be updated on all assessment scheduling & treatment of services?
PLEASE BE ADVISED: If this person fails to respond to NGS HSS Specialists on 3 or more occasions in a month, a 30-day termination notice will be served.

At time of referral, you may submit any other supporting documents (if you have them available):

*Most current Diagnostic Assessment *Copy of Functional Assessment / LOCUS *County Case Plan *Crisis Plan *etc.
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Referrals and copies of documents can be mailed or e-mailed to:

NAFRIM GROUP SERVICES LLC

6695 93RD ALCOVE S,

COTTAGE GROVE, MN 55016

E-mail:nafrimgroup@gmail.com

OR

E-mail: info@nafrimgroupservices.com

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