DHS-8507-ENG 10-24 (1.1.3)

Complex Transitions Referral Form

If you are a hospital or institution, please do not complete this form until you have contacted a lead agency.

For a list of lead agency contacts: County and Tribal Nation offices / Minnesota Department of Human Services (mn.gov)

If this person has not been able to discharge for less than a week, please reach out to the lead agency for support and do not submit the form.

If you are a lead agency, please connect with the hospital or institution to complete the information below.

Fields marked with an asterisk (*) are required.

Person's Information

PERSON'S FIRST NAME

PERSON'S LAST NAME

PERSON'S PREFERRED NAME

DATE OF BIRTH

GENDER IDENTITY

PMI

PREFERRED LANGUAGE

SPECIFY OTHER LANGUAGE

RACE/ETHNICITY

HOSPITAL/INSTITUTION

HOSPITAL NAME ADDRESS

PERSON'S DIAGNOSIS

Reason person is in the facility? (check all that apply)

Legal involvement

Substance use

Mental illness

Behavioral health

Illness or injury

Not a shared definition of safe discharge environment

Readmission before 72 hours of discharge

Has a release of information been obtained to communicate with the Complex Transitions team?

Yes

Lead Agency/Team Contact Information

LEAD AGENCY/TEAM

TYPE OF CONTACT (check all that apply)

Child welfare/Child protection

Commitment

Targeted Case Management

Unknown

Waiver

Other

SPECIFY OTHER CONTACT

LEAD WORKER'S FIRST NAME

LEAD WORKER'S LAST NAME

LEAD WORKER'S EMAIL ADDRESS

Reason for Referral

First day in ED/Day of admit to inpatient

If this person has not been able to discharge for less than a week, please reach out to the lead agency for support: County and Tribal Nation offices / Minnesota Department of Human Services and do not submit the form.

Is there a plan for their discharge? (Select yes, even if there is a plan but a delay in the plan)

Yes

What is the reason for the referral? (Check all that apply)

Assessments

Navigating Lead Agency Barriers

Navigating Licensing Barriers

Navigating Policy Barriers

Options for Discharge to a Community Location

Other

Provide more information based on your selection for the referral reason.

SUBMITTER'S FIRST NAME

SUBMITTER'S LAST NAME

SUBMITTER'S EMAIL ADDRESS

If you would like a copy for your record, you must print the completed form.

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