Instructions: This form is to be completed by the Coordinated Entry manager at the time of referral to the housing provider. The form should only be used for referrals for individuals or households that are not currently in HMIS due to data privacy reasons (e.g., a domestic violence referral, an unaccompanied minor or someone not consenting to participate in HMIS). 

Purpose	The purpose of this form is to confirm that the household identified below meets the criteria of "High Priority Homeless" as defined by Minnesota Housing. This form should be placed in the client's paper file or uploaded into the ”File Attachments” of the client’s ServicePoint profile so it is readily available for review for funder monitoring and compliance.	
High Priority Homeless Definition	Households (individuals, families with children or youth) prioritized for permanent supportive housing through the Coordinated Entry (CE) system.  	

Head of Household Name	     	
Date Household was placed on the CE Priority List	     	
Date Household was referred to the Housing Provider by the CE Manager	     	

VI-SPDAT Score	     	
Other eligibility information for this household that is needed by the specific housing provider
(disabling condition, chronic or LTH, etc.)	     

Confirmation of Coordinated Entry Manager	
I confirm that this household is a high priority for supportive housing on the Coordinated Entry waiting list for this service area.

Name of Coordinated Entry Manager	     	
Signature 		
Date