Name: Premier Service
Address: 333 Washington Ave N, Ste. 301, Minneapolis, MN, 55401, US
Telephone: 612-843-4747
Price range: Medical Assistance & waiver funded

Referral form

Pick a service first — additional fields will appear for Employment and Respite referrals. Required fields are marked with an asterisk.

1. Service requested

Which service is this referral for? *

2. About the referrer

Referrer name *

Title / role

Referrer organization / agency

Phone *

Email *

Fax

3. Client information

Client name (Last, First MI) *

Date of birth

Client phone

County

Notes / additional info

Street address

City

State / ZIP

Home phone

Cell phone

Preferred contact method

Primary language

Interpreter needed?

Legal guardian / responsible party

Relationship to client

Guardian phone

Guardian email

4. Funding & waiver

MA / Medicaid ID #

Medicare ID #

Waiver type (check all that apply)

Case manager / care coordinator

CM phone

CM agency

CM email

County of financial responsibility

Service authorization #

Authorization start date

Authorization end date

5. Employment services requested

Employment service type

Employment Exploration Employment Development Employment Support

Authorized hours / units

Billing rate / procedure code

Requested frequency

Requested start date

Preferred schedule / days

Preferred location

6. Diagnoses & disability

Primary diagnosis

ICD-10 code

Secondary diagnosis

ICD-10 code

Disability category (check all that apply)

Intellectual Disability Autism Spectrum Disorder Physical Disability Brain Injury Mental Health Other

Level of care / support needs summary

7. Employment goals & interests

Employment goal

Competitive Integrated Employment Volunteer / Community Work Job Exploration / Discovery Self-Employment

Job interests / skills

Prior work experience

Desired hours per week

Transportation available?

Physical / cognitive limitations

Accommodations needed

5. Primary caregiver

Caregiver name

Relationship to client

Caregiver phone

Caregiver email

Reason for respite

6. Respite type & schedule

Respite setting

In-Home Out-of-Home Either / Both

Requested start date

Requested end date

Hours per session

Frequency

Overnight stay needed?

Preferred days / times

7. Care needs

Medical needs & medications

Mobility & transfer needs

Behavioral / communication considerations

Dietary needs / allergies

Routines & preferences

Additional comments

Reason for referral / additional comments

Consent & authorization

I confirm I have authorization to share this information and consent to be contacted by Premier Service about this referral. *

📞 Or call 612-843-4747

Make a Referral

Referral form