**If all three in Section 1 are marked "yes," then move on to Section 2. If "no" is selected for any item in Section 1, the client is not eligible for residential services, at this time.

The referred client has active IL Medicaid *

Yes

The referred client is 18+ years old *

Yes

The referred client has a mental health condition that impacts their ability to live independently *

Yes

- SECTION 2 -

Select "has resource/ability" if the client has the resource/ability, "focus area" if this is an area of need to focus services on, and "N/A" if it does not apply.

Income

SSI *

SSDI *

Other income *

SNAP benefits *

Transportation

Walks or rides bike *

Takes the bus (has bus pass) *

Owns a vehicle *

Rides with others *

Willing to learn to take the bus *

Daily Living Skills

Showers independently *

Does laundry independently *

Dresses self independently and manages daily hygiene needs *

Has the ability to understand simple problem-solving steps *

Has the ability to follow safety protocols 24/7 without supervision *

Has positive family supports *

Has positive peer supports *

Employment/Education Goals

Employment (FT or PT) *

Education (FT or PT) *

Volunteer work (FT or PT) *

- SECTION 3 -

Substance use and recent treatment history - check "yes" or "no" and if there is a period of at least 30 days sobriety (due to the supported living structure, 30 days minimum sobriety is required and if there is a recent history of substance use, involvement in AA/NA or a treatment recovery program is required).

Issues with alcohol *

Yes

*If yes, sobriety for 30 days or more? *

Yes

N/A

Issues with Cannabis *

Yes

*If yes, sobriety for 30 days or more? *

Yes

N/A

Issues with opioids/pain meds *

Yes

*If yes, sobriety for 30 days or more? *

Yes

N/A

Issues with stimulants *

Yes

*If yes, sobriety for 30 days or more? *

Yes

N/A

- ADDITIONAL DOCUMENTS -

Please upload a release of information form and any supporting documents (mental health evaluation, substance abuse evaluation, progress notes, treatment plans, releases, etc). If the client is receiving probation services, please include the probation prescreening and screenings, and if available, any other documents detailing the client's arrest charges or summary of the event.

Thank you for submitting the Residential Services Referral Form.

Here are the next steps…

-Once the form is submitted, the referral source/individual will be notified of their placement on the waitlist, if applicable. If the individual does not want to remain on the waitlist, two alternative housing options will be provided.

-Once the form is approved and the individual wants to remain on the waitlist, a consultation will be scheduled with the referral source within one week. **The consultation is NOT admission into the program.

-Ongoing consultations and updates with the referral sources will occur throughout the individual’s placement on the waitlist.

-When the individual reaches the #3 spot on the waitlist, a final consultation with the referral source will be completed to ensure the individual is still eligible for the program.

-In addition, a screening will take place, in which the Director and individual meet in person to talk about the program, answer questions and determine the appropriateness of the individual. **The screening is NOT admission into the program.

-The referral source and/or individual will be notified of the decision to move forward with an initial assessment or be given two other housing options. The initial assessment will be scheduled on the day of determination and be completed within one week (scheduling initial assessments is not applicable for internal Transitions staff).

Please direct any additional questions to Shana DeCook, Residential Manager, at sdecook@transmhs.org.

Hours:
Monday-Friday 8:00am-4:30pm

New Client Appointment: (309) 283-1228
For Youth Therapy Services: (309) 429-6231
Main Phone Directory: (309) 793-4993
Email: transitions@transmhs.org

Mailing Address: PO Box 4238, Rock Island, IL 61204

Administrative Offices and Residential Services
805 19th Street, Rock Island, IL 61201
P (309) 793-4993 | F (309) 793-9053

Offices for Adult Therapy, Community Outreach, Employment and Psychiatric Services
2326 16th Street, Moline, IL 61265
P (309) 283-1228 | F (309) 743-2277

Offices for Youth Therapy, Community Outreach and Employment Services
2202 18th Avenue, Rock Island, IL 61201
P (309) 429-6231 | F (309) 517-2073

~ Transitions is LGBTQ+ Friendly and a Transgender Safespace ~

Join Our Team