EmailMeForm
Zumbro House Referral Form
Please use this online form for all CRS and ICS Apartment (supported apartment) programs. To expedite your referral, please also email a copy of the client's CSP, CSSP, and MnChoices Assessment. Email to: conken@zumbrohouse.com
Your Name
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First
Last
Referring Person's Relationship to Individual
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Phone Number
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Email
*
Name of Person Being Referred
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First
Last
Age
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Sex
*
Male
Female
County of Financial Responsibility
*
Location of Desired Placement
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Primary Diagnosis
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Level of care desired
CRS - 4 bed group home model, designed for higher support needs individuals
ICS Apartment - Supported apartment model, designed for lower support needs individuals
Unsure which level care would be best?
Need Accessible Home?
*
Yes
No
Guardianship Status
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. Include behaviors such as: physical aggression, verbal aggression, drug or alcohol abuse, sexual offending, med non-compliance, self harm, elopement from supervision, etc.
Is the person under civil commitment? Is the person on probation or parole? Please describe.
Does the person have a waiver - CADI, DD, BI, EW? If so, which one.
The waiver funds the program/staffing.
Name of CADI Case Manager
Email address of CADI Case Manager
Additional Comments
If you would like to schedule a tour, please advise a date and time Mon-Fri 9am-4pm.
