Housing Application 2

If at any time you need to save your progress to complete later, simply click "Save" at the bottom and you can finish off where you started.


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 field with unknown or N/A. Do not leave any blank fields. If you have any questions please call the Alliance Care Office on 952-767-4910


We will be gathering information about the following, so please gather all relevant resources to ensure you can complete the application to the best of your ability.


Part A: Applicant Personal Information
Part B: Legal Background
Part C: Financial Information
Part D: Referral Information
Part E: Past residence / placement information
Part F: Functional information
Field is required!
Field is required!
What is your preferred Language?
  • - select a option -
  • English
  • Spansih
  • Somali
  • Hmong
  • Arabic
  • Other
- select a option -
Field is required!
Field is required!
If other Language, enter below:
Language
Field is required!
Field is required!
Do you have accessibility needs ?
  • - select a option -
  • No
  • Legally blind
  • Hard of Hearing
  • Vocally impaired
  • Other
- select a option -
Field is required!
Field is required!
If other need, enter below:
Other Need
Field is required!
Field is required!
What other services are you receiving?:
Type in other services you are receiving. Type "None" if none.
Field is required!
Field is required!
This form is entirely in English. if you need help please call the Alliance Care Office on 952-767-4910
Field is required!
Field is required!

Part A: Applicant Personal Information

(Applicant should fill out this area, may use assistance)
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Select a date
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Your Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
  • Minnesota
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
Minnesota
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
What city is the applicant interested in applying to *
Field is required!
Field is required!
Gender:
Field is required!
Field is required!
If other, please enter gender below
If other, please enter gender below
Field is required!
Field is required!
List all present medical diagnosis (Please keep in mind we are not wheelchair accessible at this time)
Type Here:
Field is required!
Field is required!
What is the applicants current living situation ?
Field is required!
Field is required!
If other living situation, enter below:
Other Living Situation
Field is required!
Field is required!
Is the applicant currently pregnant?
Field is required!
Field is required!
If Yes to above question, when is your due date?
Select a date
Field is required!
Field is required!
Does the applicant any pets?
Field is required!
Field is required!
Does the applicant have a drivers license?
Field is required!
Field is required!
Does the applicant own their own vehicle?
Field is required!
Field is required!
Does the applicant plan to have a roommate?
Field is required!
Field is required!
This completes Part A of the application, press "Next" to continue.
Field is required!
Field is required!

Part B: Legal Background

Please note, answering Yes will not necessarily disqualify you
Has the applicant ever been arrested?
Field is required!
Field is required!
Has the applicant ever been convicted of a crime?
Field is required!
Field is required!
If Yes to the above, please state if it was a misdemeanor or felony. Describe and include dares and status of cases.
Type Here:
Field is required!
Field is required!
Is the applicant currently on probation?
Field is required!
Field is required!
If Yes to the above, please enter name & phone number of probation officer
Field is required!
Field is required!
Is applicant currently on parole?
Field is required!
Field is required!
If Yes to the above, please enter name & phone number of parole officer
Field is required!
Field is required!
What are the applicants probation requirements if any?
Type Here:
Field is required!
Field is required!
This completes Part B of the application, press "Next" to continue.
Field is required!
Field is required!

Part C: Financial

Please provide the most accurate information to the best of your knowledge.
What type of waiver does the applicant have?
Field is required!
Field is required!
If other, please enter Waiver
If other, please enter Waiver
Field is required!
Field is required!
Primary income sources (Check all that apply)
Field is required!
Field is required!
If other, please enter Income Source
If other, please enter Income Source
Field is required!
Field is required!
What is the applicants total monthly income from all sources?
Enter only numbers, not symbols like $
ex: 100
Field is required!
Field is required!
Does the applicant have any spend downs or garnishments? If so - please detail.
Type Here:
Field is required!
Field is required!
Financial management (check all that apply)
Field is required!
Field is required!
If other, please enter other financial management
If other, please enter financial management
Field is required!
Field is required!
This completes Part C of the application, press "Next" to continue.
Field is required!
Field is required!

Part D: Referral Information

Please provide below information or attach county referral form
How immediate is placement needed? If less than 4 weeks, why?
Type Here:
Field is required!
Field is required!
Name of person making referral
Full Name
Field is required!
Field is required!
Relationship to applicant
Field is required!
Field is required!
Living arrangement sought
Field is required!
Field is required!
If other, please enter other living arrangement sought
If other, please enter living arrangement sought
Field is required!
Field is required!
Case Manager Name
Enter Full Name
Field is required!
Field is required!
Case Manager Email
example@example.com
Field is required!
Field is required!
Case Manager Phone
Please enter a valid phone number.
Phonenumber
Invalid phonenumber!
Invalid phonenumber!
This completes Part D of the application, press "Next" to continue.
Field is required!
Field is required!

Part E: Placement History

Please detail where or with whom the applicant has lived in the last 4 years. Include out patient sites, family IRTS and residential placements.

Location #1

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
Field is required!
Field is required!
If Other, please enter living situation
If Other, please enter living situation
Field is required!
Field is required!
From
date started living at location/date started being homeless
Select a date
Field is required!
Field is required!
Until
date stopped living at location/date stopped being homeless
Select a date
Field is required!
Field is required!
Location address is:
Street Address
Field is required!
Field is required!
City
Field is required!
Field is required!
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Contact Email Address
Reference Email Address
Field is required!
Field is required!
Contact Phone:
Reference Phonenumber
Invalid phonenumber!
Invalid phonenumber!

Location #2

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
Field is required!
Field is required!
If Other, please enter living situation
If Other, please enter living situation
Field is required!
Field is required!
From
date started living at location/date started being homeless
Select a date
Field is required!
Field is required!
Until
date stopped living at location/date stopped being homeless
Select a date
Field is required!
Field is required!
Location address is:
Street Address
Field is required!
Field is required!
City
Field is required!
Field is required!
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Contact Email Address
Reference Email Address
Field is required!
Field is required!
Contact Phone:
Reference Phonenumber
Invalid phonenumber!
Invalid phonenumber!

Location #3

Applicant Lived At
  • - select a option -
  • Apartment
  • Shelter
  • Group Home
  • Homeless
  • Roommate/Family
  • Other
- select a option -
Field is required!
Field is required!
If Other, please enter living situation
If Other, please enter living situation
Field is required!
Field is required!
From
date started living at location/date started being homeless
Select a date
Field is required!
Field is required!
Until
date stopped living at location/date stopped being homeless
Select a date
Field is required!
Field is required!
Location address is:
Street Address
Field is required!
Field is required!
City
Field is required!
Field is required!
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
Contact Email Address
Reference Email Address
Field is required!
Field is required!
Contact Phone:
Reference Phonenumber
Invalid phonenumber!
Invalid phonenumber!
Has the applicant been evicted within the last 12 months?
Field is required!
Field is required!
Has the applicant had an involuntary service termination within the past 12 months?
Field is required!
Field is required!
This completes Part E of the application, press "Next" to continue.
Field is required!
Field is required!

Part F: Functional Information

Please provide information relating to the last 12 months.
For any of the following questions, if your answer is No - simply enter "Unknown" or "N/A" If Yes, please explain.
Does the applicant have a history of recurrent violent behaviours in the last 12 months? (Examples include Physical Aggression, Agitation, Verbal Aggression, Sexual Coercion or Aggression).
Type here
Field is required!
Field is required!
Does the applicant have a history of drug or alcohol use in the past 12 months?
Type here
Field is required!
Field is required!
Does the applicant have a history of Self injurious behaviors or Suicidal Ideation and/or Attempt within the last 12 months?
Type here
Field is required!
Field is required!
Does the applicant have a history of property destruction within the last 3 years?
Type here
Field is required!
Field is required!
Does the applicant have ability to safely utilize appliances (Gas stove, Electric stove, Microwave)
Type here
Field is required!
Field is required!
Has the applicant been hospitalized in the past 12 months?
Type here
Field is required!
Field is required!
Has the applicant had any falls in the past year?
Type here
Field is required!
Field is required!
Does the applicant have a history of Medication Non-Compliance in the past 12 months?
Type here
Field is required!
Field is required!
Has the applicant had any MAARC reports in the past 12 months?
Type here
Field is required!
Field is required!
Are there any other safety or behavioural concerns to consider for this applicant?
Type here
Field is required!
Field is required!

Upload your files

Please upload relevant files to support your application including CSSP, MN Choices Assessment, Face Sheet etc...
Upload your documents...
Field is required!
Field is required!

Declaration

By signing below, I certify that the information included in this form is correct to the best of my knowledge.
Name of person completing this form:
Full Name
Field is required!
Field is required!
Relationship to applicant:
Field is required!
Field is required!
Signature:
Field is required!
Field is required!
Sign Date:
MM-DD-YYYY
Field is required!
Field is required!
Awesome! This completes your application. The next step is to sign the release of information so that we can begin to process your application.
Field is required!
Field is required!

Release of Information Authorization

Please read and sign the following so that we can begin to process your application.
I have reviewed the Notice of Use and Disclosure Practices.

I understand that the requested Protected Health Information, criminal background information, and rental history will be used by Alliance Care for the purpose of home health care.

I hereby authorize verbal and written communication from Alliance Care and in addition, agree to release:


The following portions of my clinical record

History and Physical
Discharge Summary
Consults
Plans of Care
Current/ Past Progress Notes
CSSP
MNchoice Assessment
Mental Health Records
Chemical Dependency Records
Operative Reports
Health Care Directives
Medication List (including Pharmacy Communication)
Physician's Orders
Flow Sheets
POLST (Health Care Directive)
Medical/Health information


And the following portions of other records to Alliance Care including:

Criminal Background Check via BCA or other sources
Rental History Verifications within the last 5 years
Case Management Records
Please read through the declaration below and sign and date at the bottom.
I understand that the records will be used to continue evaluation or treatment, coordinate services, and determine eligibility for services.


I understand that my records are protected by data privacy regulations. Alcohol and drug abuse records may be protected by Federal Law (42 CFR Part 2). These records cannot be released without my consent unless specifically directed by law.


I understand that I have the right to refuse to sign this consent.


I understand that I may withdraw or revoke this consent at any time if the action it authorizes has not been carried out.


I understand that this consent expires one year from the date I signed it.


A copy of this authorization shall be considered as effective and valid as the original.
Field is required!
Field is required!
Resident / Resident Representative Full Name
Full Name
Field is required!
Field is required!
Relationship to resident
Field is required!
Field is required!
Signature:
Field is required!
Field is required!
Sign on:
MM-DD-YYYY
Field is required!
Field is required!
Awesome! This completes your application. The next step is to sign the release of information so that we can begin to process your application.
Field is required!
Field is required!