DHS-8507A-ENG 2-26 (1.0.2)

Complex Transitions – Expanded Supports Referral Form

This form is intended for use by DHS partners, Tribal Nations, lead agencies, people, and providers to request support from the Complex Transitions team related to people who need expanded support transitioning to community services as a result of program closures, evictions or service disruptions in residential settings, and other situations related to provider program integrity.

Fields marked with asterisk (*) are required.

Person's Information

PERSON'S FIRST NAME

PERSON'S LAST NAME

DATE OF BIRTH

GENDER IDENTITY

PREFERRED LANGUAGE

SPECIFY OTHER LANGUAGE

RACE/ETHNICITY

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

Reason for Referral

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

Assessments

Navigating Lead Agency Barriers

Navigating Licensing Barriers

Navigating Policy Barriers

Non-payment to Provider

Options for Discharge to a Community Location

Services accessed have ended

Other

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

Submitter's Contact Information

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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