• Supportive and Supervised Living Interest List Form

  • This form contains 3 sections and may take some time to complete:

    1. Basic Information & Contacts
    2. Medical & Support Information
    3. Housing Information

    If you need to Save & Continue Later, you may do so by following the directions in the PDF below.

    Upon submission, you will receive an email confirmation that includes the content you submit, and you can expect to hear back from us in about a week.

    If you have any questions about this process, or the services offered at Fraser, please call our Community Inclusion Intake Coordinator at 612-767-5180 or email us at CommunityInclusion@fraser.org

  • Basic Information & Contacts

  • Format: (000) 000-0000.
  • Relationship to the Individual*
  • Format: (000) 000-0000.
  • Individual Date of Birth*
     - -
  • Sex Assigned at Birth*
  • Pronoun Use*
  • Gender Identity*
  • Is an interpreter needed?*
  • Does the individual have any pets or Emotional Support Animals?*
  • Does the individual have a legal guardian?*
  • Guardian Type*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the individual have a Contracted Waiver?*

  • Fraser Supportive & Supervised Living services are typically paid for through Contracted Case Management Waiver funding, however we also accept private payment.

    For information about MA visit Disability Hub:

    https://disabilityhubmn.org/top-topics/health/medical-assistance/

  • Format: (000) 000-0000.
  • Who is the best person to contact? (select all that apply)*

  • Medical & Support Information

  • Does the individual need an accessible location?*
  • Does the individual have a history of (select all that apply):*
  • Can the individual be home alone safely for at least 5 hours?*
  • Does the individual know how to respond in an emergency situation?*
  • Does the individual have any restrictions we should know about?*

  • Housing information

  • Which Service Type(s) are you interested in?*

  • Supervised Living (Houses)

  • What is the housemate gender preference? (select all that apply)*
  • Which Supervised Living location(s) are preferred? (select all that apply)*
  • Do they require awake overnight staffing?*

  • Supportive Living (Apartments)

  • What is the apartment style preference? (select all that apply)*
  • Which Supportive Living location(s) are preferred? (select all that apply)*
  • Are there any concerns about the individual passing a background check with the property manager?*

  • Document Upload

  • Please upload copies of any person-centered paperwork.  This could include:

    • The individuals Support Plan, Support Plan Addendum (formerly CSSP Addendum), IAPP, SMA, ADL/IADL
    • Any incident reports, record of law enforcement and/or 911 involvement
    • Medical documentation (including hospital visits and active diagnosis list)
    • Any additional documents that can best describe the individuals’ strengths, preferences, and support needs
    • Releases of information

    The main document we typically receive is the Support Plan.

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