Client Referral Form

Fill this out and press Submit Referral — it goes straight to our Assisted Living Director. We respond within 24 hours, often the same day. Questions: (763) 222-6062.

Prefer paper? Download the Referral Packet (fillable PDF) and fax it to (763) 260-9940 or email it to abundancehomemn@gmail.com.

Referring Case Manager

Case manager name *

Agency / county *

Phone *

Email *

Fax

Client Information

Client full name *

Date of birth *

Gender

PMI / MA #

Current living situation / address

Guardian / representative (name & relationship)

Guardian phone

Funding & Placement

Waiver span / authorization dates

If other funding, describe

Preferred home

Desired move-in date

Care Needs

Documents

Documents you will send or are attaching

Attach a document (optional)

One file, up to 8 MB. You can also fax documents to (763) 260-9940 or email them to abundancehomemn@gmail.com.

Additional notes

By submitting, you confirm you are the client’s case manager or authorized representative.