Referral Forms

If you are seeking housing or are a referrer looking for the necessary resources, please choose the correct tab below. Also available are some of the most frequently asked questions regarding our programs.

House of Charity would like to keep you updated on our openings for both our on-site supportive housing and our out-patient treatment with the option of lodging beds. Please click here to register.

For general program and intake questions not answered on this page, please contact our intake coordinator: or 612-594-2006

Day by Day Chemical Dependency and Mental Health Treatment

Day By Day is our 120-day outpatient program for women and men 18 years of age and older that offers a total quality of life approach to co-occurring Chemical and Mental Health Treatment.

To make a referral to Day by Day Co-occurring Intensive Outpatient Treatment (IOP), with the option of lodging, please fax the following documents below:

  • An Updated Rule 25 assessment (completed with-in the past 30 days)
  • Recent Progress note
  • Health insurance information (M.A./Consolidated funding/Ucare/BlueCross, etc.).
  • Professional Statement of Need – if the client intends to receive lodging services

Please fax all completed information to 612-594-2030 Attn: Treatment Intake. The Treatment Director will contact you once all the information has been received.

Instructions on how to complete the Third Party and Professional Statement of Need Forms

  • Third Party form – Please list at least 4 episodes of homelessness in the past 3 years.
    • Please exclude jail, hospital stays, treatment facilities, sober housing, and other GRH programs, etc.
    • Please list start and end dates, city, state, and the name of the facility or address.
  • Professional Statement of Need form
    • On the first page, please fill in the applicant’s information to the best of your knowledge and have the applicant sign.
    • The second page – on the top section, please check at least 1 reason, for supportive services. On the bottom section, please check at least 2 reasons.
      • A signature of the qualified licensed professional is required for this form. Please see for to determine which professional is qualified to complete this form.