Wecare
Menu
Home
About Us
What we offer
Housing Stabilization Services
Behavioral Health Services
Adult Day Services
PCA/CFSS
Referrals
Careers
Contact Us
Employee Login
Register
Employee
Logout
Client Login
Phone : 320-281-4449
Fax : 320-281-4819
Employee
Login
Register
Logout
Phone : 320-281-4449
Fax : 320-281-4819
Client Login
Menu
Home
About Us
What we offer
Housing Stabilization Services
Behavioral Health Services
Adult Day Services
PCA/CFSS
Referrals
Careers
Contact Us
Login
Employee
Register
Logout
Client Login
Menu
Home
About Us
What we offer
Housing Stabilization Services
Behavioral Health Services
Adult Day Services
PCA/CFSS
Referrals
Careers
Contact Us
Phone : 320-281-4449
Fax : 320-281-4819
Adult Day Service referrals
ARMHS service referrals
Housing Stabilization referrals
PCA referrals
Statement of Non-discrimination
Language
English (US)
WeCare Referral
Housing Stabilization Services
Patient name
*
First Name
Last Name
Patient's Address
*
House name/no & street
City
Please Select
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Postcode
Patient's Mobile Phone
*
Patient's Email address
example@example.com
Patient DOB
*
-
Month
-
Day
Year
Ethnicity
Please Select
Black
Caucasian/White
Hispanic
Asian
Disability
*
Yes
No
Gender Identification
Male
Female
MA#
*
Medicare
Yes
No
My Client will need help finding housing
*
Yes
No
My Client has a housing subsidy
*
Yes
No
What type of Housing subsidy and how much?
Client Current Residence
*
Nursing Facility
Hospital
Shelter
Own Apartment/Home
Homeless/No place to live
Other
Currently "at risk" of losing housing
*
Yes
No
Reason for referral/Brief Description of Participants circumstances
*
Primary Diagnosis
*
Recent History(Check all that apply over the past 12 months)
Self Injurious behavior
Aggressiveee/Violent behaviours
Medication non-compliance
Drug/Alcohol abuse
High medical needs
Other
Insurance Type
*
Blue Cross
Ucare
Medica
Health Partners
Other
Attachments
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Which of the following documents are attached to show proof of disability
*
Professional Statement of Need
Medical Opinion Form
Proof if recipient SSI or SSDI
Or over 65 years of age (65+ automatically qualifies ) shown through valid ID
Which of the following documents are attached to show proof that the person is facing housing instability
*
Professional Statement of Need
MnCHOICES Assessment
Coordinated Entry Assesment
Referrer's information
Referrer's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Case Manager
First Name
Last Name
CM Phone Number
Please enter a valid phone number.
CM Email
example@example.com
Data protection
*
Client understands and accepts that their information will be kept securely until it is no longer required to assist them or by law. Permission is granted to WeCare to contact the client by their identified preferred contact method.
Submit
Should be Empty:
