Meridian Services Residential Housing Application

Meridian Services Residential Housing Application

For questions, please contact Meridian Services at 763-450-5000
Thank you for your interest in Meridian Services Residential Housing. Please take some time to collect the materials necessary to fill out the application. There is currently no way to save the application, so please set aside 15-30 minutes to complete.

You will need:
- Basic contact information for the referrer
- Information on the person seeking servcies
- Digitial copies of the CSSP and CSP, IAPP, IEP (If under 21 years old), a psychological assessment stating the person's disability, and the Positive Supports Behavior Plan to upload to the application
Referrer

This is the person that is referring a Participant for services. Examples include, but are not limited to: Social workers, Case managers, Parent/Guardians, Transition Specialists, Community Health Workers, etc.
Legal Name of Referrer*

First NameLast Name
Title*
County*
Email of Referrer*
example@example.com
Phone Number*
(000) 000-0000
Person Seeking Services

This is the person that wishes to receive services. Other terms include, Participant, Consumer, Client, or Person Served
Legal Name of Person Seeking Services*

FirstMiddleLast
PMI #*
Type of Waiver*
Any Current or Past Criminal Charges?*

YesNo
If yes, please describe
Current Living Arrangement*

Home with parents/guardiansCrisis HomeResidential ProviderHospitalOther
Primary Reason for seeking residential services with Meridian Services Inc. *
Documentation
Please attach the following documentation, which is required to complete the application.
1. County CSSP and CSP
2. IAPP
3. IEP (if under 21)
4. Psychological assessment stating the person’s disability
5. Positive Support Behavior Plan
Please upload files here*

Cancelof
Please verify that you are human*
Should be Empty:

Meridian Services Residential Housing Application

Referrer

Person Seeking Services

Documentation