Positive Support Services Enrollment Application

Section 1: Referral Information
Name of Person Making Referral:*
Reason for Referral:*
Select Primary Area of Concern*
- Developmental Concerns
- Behavioral Concerns
- Mental Health Needs
- Sensory Issues
Primary Behaviors of Concern:*
Has Person Received Positive Supports in the Past?*
- Yes
- No

Section 2: Participant Information
Full Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Guardian:*
First Last
Emergency Contact Information:*
Please include first and last name & their relationship to the individual
Case Manager Name & Contact Information:*

Section 5: Consent & Rights
Consent for Services:*
Signature Date
Guardian Signature (if applicable):
Signature Date
I Certify That the Participants Rights Were Explained and Provided:*
- Yes
- No
Section 8: Staff Notes
Initial Assessment Summary:
Recommended Positive Support Strategies:
Assigned Qualified Professional:*
Full Name of Person Making Referral*
Phone Number of Person Making Referral*
Email Address of Person Making Referral*
How Did You Hear About Opportunity Partners Positive Support Services?*
Minnesota DHS required to comply with MN Statute 245D Positive Support Strategies & Restrictive Procedures. Intake forms must be person-centered and include consent, rights, and individualized supports. Please review and fill out Opportunity Partners Choice of Service Attestation

Section 1: Referral Information