2300 Hastings Ave., Newport, MN 55055
Referring Person's Relationship to Individual (if referring yourself, type "self")
Name of Person Being Referred
If funded by HCBS Waiver, County of Financial Responsibility
No guardian (own guardian)
Has a guardian - family member
Has a guardian - private/paid guardian
Describe any significant health issues (diabetes, TB, etc.), ambulation (walking) issues, or sensory issues (blind, deaf, etc)
Behavioral History - Please describe the behaviors that have presented a problem for the person, including the frequency and intensity.
Other identified areas of needed support
Does the person have a waiver - CADI, DD, BI, EW? If so, which one.
The waiver funds the program/staffing.
Name and email of CADI Case Manager (if applicable)
If you would like to be contacted about reserving an apartment or joining the waiting list, what phone number or email address do you wish to be contacted.