2. MN Department of Human Services Professional Statement of Need
4. Name:*
5. Date of Birth:*
   Date of Birth:
7. Housing Provider Name: (if available)
8. MAXIS Case Number (if available)

10. Qualified Professionals (as defined in Section 2) use this form to confirm that a person meets certain criteria for one or both of the following:

    • Medical Assistance Housing Stabilization Services

    • Minnesota Housing Support Program

    After completing this form, please return to the person or their authorized representative.

    This request does not represent an offer of payment on the part of the state, county, or tribe.

12. Do you authorize the Qualified Professional to release your information? (read and sign below)

    I give permission for the Qualified Professional below to release the requested information to the Minnesota Department of Human Services as well as the county or tribe administering the programs. I know that the information will be used to determine my eligibility for the Minnesota Housing Support Program as well as Medical Assistance Housing Stabilization Services. I know this authorization will end one year from the date I sign it.

    State and Federal privacy laws protect my records. I know:

    • Why I am being asked to release this information

    • I do not have to consent to this authorization, but it may affect my benefits or services if I do not give my consent

    • I am giving my written consent for this person/agency to give out this information

    • I may stop this authorization with a written notice at any time, but this written notice will not affect information the agency has already requested

    • The person or agency who gets my information may pass it on to others.

14. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
16. Applicant Signature:*
17. Todays Date:*
    Todays Date:
19. Section 1: Housing Situation*
    -- Select One --I am currently homeless.I am at risk of losing my housing.I am living in, or I have recently transitioned from, an institution (ex. hospital or nursing home) or congregate facility (ex. board and lodge, foster home, assisted living).I am eligible for waiver services (BI, CAC, CADI, DD, EW).I was homeless before entering a correctional, medical, mental health, or substance use disorder treatment center and now I am discharging without a permanent place to live.

    What is your current situation?

21. Section 2: Disabling Condition*
    -- Select One --Developmental DisabilityLearning DisabilityMental healthPhysical illness, injury, or incapacitySubstance Use Disorder

    A certified disability determination or formal diagnostic assessment is not required (check one).

22. Allowable qualified professional

    Mental health professional, licensed school psychologist, a physician, a nurse practitioner, a physician assistant, or certified psychometrist working under the supervision of a licensed psychologist.

    Licensed psychologist or school psychologist with experience determining learning disabilities.

    Licensed psychiatric registered nurse, licensed psychiatric nurse practitioner, licensed independent clinical social worker (LICSW), licensed professional clinical counselor (LPCC), licensed psychologist (LP), licensed marriage and family therapist (LMFT), or licensed psychiatrist.

    Licensed physician, physician's assistant, nurse practitioner, or licensed chiropractor.

    Treatment director, alcohol and drug counselor supervisor, or licensed alcohol and drug counselor (LADC).

24. This condition is current and expected:
    -- Select One --To last at least one year.To last less than one year,
25. If lasting less than one year, estimated date:
    If lasting less than one year, estimated date:
27. Name of Qualified Professional:
28. Title/ Licensure:
30. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Electronic Signature
33. Todays Date:*
    Todays Date:
35. Are you a County designee?*
    -- Select One --YesNo
36. If yes, which county?
38. Section 3: Medical Assistance Housing Stabilization Services
    -- Select One --Communicating needsMobilityMaking informed decisionsManaging moods or behaviors

    This Section must be completed by a Qualified Professional. Please identify areas in which the person needs support to find or maintain stable housing.

40. Name of Qualified Professional:
41. Title/Licensure:
43. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
45. Electronic Signature
46. Todays Date:
    Todays Date:
48. Section 4: Minnesota Housing Support Supplemental Services
    -- Select One --Tenancy supports to assist an individual with finding their own home, landlord negotiation, securing furniture and household supplies, understanding and maintaining tenant responsibilities, conflict nSupportive services to assist with basic living and social skills, household management, monitoring of overall well-being, and problem solving.Employment supports to assist with maintaining or increasing employment, increasing earnings, understanding and utilizing appropriate benefits and services, improving physical or mental health, movingHealth supervision services to assist in the preparation and administration of medications other than injectables, the provision of therapeutic diets, taking vital signs, or providing assistance in dr

    This Section must be completed by a Qualified Professional or County Designee. Please indicate which support(s) the person needs to access or maintain housing.

50. (PERSON'S NAME) who has an illness or incapacity which limits their ability to work and provide self-support, and needs assistance to access or maintain housing
52. Name of Qualified Professional:
53. Title/ Licensure:
55. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Electronic Signature
58. Todays Date:
    Todays Date:
60. Are you a county designee?*
    -- Select One --YesNo
61. If yes, which county?
63. Section 5: Transition from Residential Treatment to Minnesota Housing Support Program

    This Section must be completed by Behavioral Health Treatment Staff.

    Note: Sections 2 and 3 of this form are not required for completion of this section. Residential treatment staff completing this section may be the same as the Qualified Professional listed above.

65. Name of person that lacks a fixed, adequate, nighttime residence upon discharge

    Name:

66. Name of residential treatment program person is discharge from?

    Treatment facility name:

67. Date person exited treatment facility program?
    Date person exited treatment facility program?
69. Name of treatment staff:
70. Title/ Licensure:
72. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
74. Electronic Signature
75. Todays date:
    Todays date:
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field