Client Name * First Name Last Name Client Date of Birth * Client Phone Number Referring Person * Self Agency Provider Family Member Or Friend School Other Referring Person's Name (if not self) First Name Last Name Do You Have Housing Focused Person Centered Plan? * Yes No Unsure Do You Have A Professional Statement of Need? * Yes No Unsure Are You Interested In The WORK IT OUT! Program Yes No I'm not sure what that is but I want to know more! Organization/School (if applicable) Phone number to contact for intake scheduling Email Preferred Method Contact Phone Call Email Text Message Thank you! Someone from our team will reach out to you within 72 hours. If you have a Professional Statement of Need, CSSP, or any other documents pertinent to this referral, please send them to referrals@lcssmn.com