Transitional Services Referral Form

Date Referral Made

Move Date

Client Name

Date of Birth

Phone Number

PMI #

Waiver

Referral Contact Information

Referring waiver manager name

Phone/Mobile

Housing Case Manager Name

Phone/Mobile

Guardian Name/Emergency Contact

Phone/Mobile

Previous Placement/Address

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone/Mobile

Storage Facility

First Name

Last Name

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

New Home/Placement

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Property Manager Name

Phone

Security Deposit/Application Fee

Security Deposit Amount

Application Fee Amount

Do we need to send a letter of guarantee?

Yes

Check made out to

Not to Exceed $1,700 of the allowable $3,000

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Move Details – Please Provide details regarding move

Moving Expense

Not to Exceed $1,700 of the allowable $3,000

If Yes for Blinds or Windows – Please provide number and measurements of the windows

Preference of Essential Furniture

Not to exceed $1,000 of the allowable $3,000 *Allotted budget does NOT allow to get all items listed *Dinning set with chairs are low in stock and maybe subject to delayed arrival or availability

Are you okay with used items?

Yes

Bed Size

Bed Pieces

Bed Frame

Mattress

Box Spring

Sofa/Couch

2 Cushion Sofa

3 Cushion Couch

Dining Table

2 chairs/bench

4 chairs/bench

Preference of Household Supplies

Not to exceed $300 of the allowable $3,000. This $300 budget does not allow for all the following items:

Please list items that can be removed if not all items fit in the budget

Cancellation and Weather Release Notice

Premier Service has the right to change the date of the Transitional Services in case of unexpected events (such as staff illness/emergency, equipment problems, client illness/hospitalization, etc.) We will do everything possible to avoid these issues affecting the move day before we make a final decision.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

Premier Service will not relocate or transport in the following weather conditions in the pick-up or drop-off county: tornado warning, severe thunderstorm warning, temperature lower than -10 degrees, blizzard, and whiteout conditions. If the relocation is called off due to weather, Premier Service will collaborate with your case managers to arrange a new relocation date. Premier Service will not assume responsibility for any additional charges resulting from this cancellation.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

I understand that Premier Service may relocate or deliver items in different weather conditions such as rain, snow, sleet, etc., with your consent. I agree that Premier Service is not responsible for any damage or exposure to moisture that the items may experience as a result of these weather conditions. Premier Service does not provide coverings or protection for belongings during relocation to protect them from the previously mentioned weather conditions.

I consent to the above cancellation policy

I do not consent to the above cancellation policy

Person Served Signature First Name

Person Served Signature Last Name

Today's Date

By signing above, you are acknowledging that you understand and agree to the cancellation and weather policies

Waiver Case Manager Signature First Name

Waiver Case Manager Signature Last Name

Today's Date

By signing above, you are acknowledging that you understand and agree to the cancellation and weather policies

Transitional Service Agreement

I acknowledge that the items listed in this referral will be bought using my transitional services funding. I understand that the designated Premier Service transitional services coordinator will do the shopping for me based on the choices in this referral. I recognize that Premier Service only uses specific vendors for furniture and household items, namely Amazon and Walmart, and will not purchase from any other vendors. According to DHS regulations, Premier Service cannot buy any electronics. Premier Service does not reimburse any payments made by the client or dispose of the client's personal belongings. All purchases are final, and Premier Service is not responsible for replacing or refunding broken or defective items. If there is any damage to your personal belongings during the move (hired by company), you have 48 hours after the move to report it. If you hire your own movers, you will need to communicate directly with them to address any damages to personal belongings. Your case will be invoiced and finalized 72 hours after the move. Once a claim is submitted to DHS, no cases will be reopened for additional purchases. Original receipts will not be provided after purchase.

Person Served Signature First Name

Person Served Signature Last Name

Date

Waiver Case Manager Signature First Name

Waiver Case Manager Signature Last Name

Date

Email

Call Us

Fax