NE CoC CES Referral Request
Use this form to submit information when requesting a referral from the Northeast Minnesota Continuum of Care Coordinated Entry Priority List.
Instructions:
1. Enter requested information about your referral request below.
2. Information will appear in the referral request spreadsheet and priority list manager will receive a notification.
3. Within 3 business days, the priority list manager will send you a referral via email.
4. Refer to the NE CoC CES Policies & Procedures for guidance.
* Required
Email address
*
Your email
Individual Requesting Referral:
*
Your answer
Agency:
*
Your answer
Program:
*
Your answer
Program HMIS Provider ID (if applicable):
*
Your answer
Date of Program Opening
*
MM
/
DD
/
YYYY
Number of Program Vacancies (per policy, 3 referrals are sent for each vacancy as allowable)
*
1
2
3
4
Other:
Type of Housing
*
Permanent Supportive
Transitional Housing
Rapid Re-Housing
Other:
Household Type Requested (select all that apply)
*
Single
Family
Youth Single
Youth Family
Either Single or Family
Required
Number of beds available for program vacancy
*
Your answer
Check all that apply: This means they MUST be these categories - not that you will accept these categories
*
Disabled
Veteran
Currently in Shelter
Currently on Street
SPMI on File
None of the Above
Other:
Required
Does your program allow for doubled up households?
Yes
No
Other:
Clear selection
Does your program require that a client reside in a specific county?
Yes
No
Clear selection
If yes, which county?
Aitkin
Carlton
Cook
Itasca
Koochiching
Lake
Other:
Other comments regarding your referral request:
Your answer
Send me a copy of my responses.
Submit
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