Contact 1 — LOGO COMMUNITY SUPPORT SERVICES

Client Name

First Name

Last Name

Client Date of Birth

Client Phone Number (No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.)

Client Email

Referring Person

Referring Person's Name (if not self)

First Name

Last Name

Have you lived in a shelter and completed a coordinated entry assessment in the past 12 months

Do you have active Medical Assistance in Minnesota

Do You Have A Housing Focused Person Centered Plan?

Do You Have A Professional Statement of Need?

Do You Have A CSSP or Care Plan

Organization/School (if applicable)

Preferred Method Contact for Intake

Phone number to call or text for intake scheduling (No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.)

(###-###-####) *Message and Data Rates May Apply*

Email for Intake Scheduling

Message

Thank you! Someone from our team will contact you within 72 hours. For any other documents pertinent to this referral, please send them to referrals@lcssmn.com with the client's name as the subject.

We will make three attempts to contact you via your preferred method before we close your referral.