Service Referral

Submit a referral for housing stabilization services. This form can be completed by case managers, social workers, or individuals seeking services.

Housing Stabilization Service Referral

Before You Submit

Client must have active Medical Assistance enrollment
All required fields marked with * must be completed
Supporting documents are optional but helpful

Client Information (Required)

First Name *

Last Name *

Client PMI/Subscriber ID *

Date of Birth *

Phone Number *

Email Address *

Service Request (Required)

Type of Service Needed *

Housing Sustaining: For individuals who have housing and need ongoing support to maintain it
Housing Transitioning: For individuals who need help finding and securing stable housing

Case Manager Information (Optional)

If this referral is being submitted by or involves a case manager, please provide their information below. This helps us coordinate care effectively.

Case Manager First Name

Case Manager Last Name

Organization/Agency

Case Manager NPI Or UMPI

Case Manager Email

Case Manager Phone

Supporting Documents (Optional)

Upload Supporting Documents

You may upload multiple files. Accepted formats: PDF, DOC, DOCX, JPG, PNG. Maximum size: 10MB per file.
Note: Files will be securely stored in a client-specific folder.

What Happens After You Submit?

Review Process

We review all referrals within 1-2 business days to determine eligibility and service needs.

Initial Contact

Our team will contact the client and case manager to discuss services and begin the intake process.

Service Coordination

We coordinate with all parties to develop an appropriate service plan and begin assistance.

Questions about the referral process?

Call Us: (952) 923-3086