Instructions: This form must be completed by a mental health professional.

Print Applicant Name:      
(To be filled in the Bridges Housing Agency)

	I hereby verify that the applicant does meet the definition of having a mental illness per Minn. Stat. 245.462, subd. 20 (a).	
	I hereby verify that the application does not meet the definition of having a mental illness2 per Minn. Stat. 245.462, subd. 20 (a).	

Documents to confirm this determination are contained in the case file of the applicant named above.	
     	
Print Name of Mental Health Professional	
     	
License/Qualification of Mental Health Professional	
     	     	
Telephone Number	Fax Number	
     	     	     	     	
Address	City	State	Zip Code	
	     	
Signature of Mental Health Professional	Date	

Return this form to the following address:
(To be filled in the Bridges Housing Agency)
	
     	
Print Name of Housing Agency	
     	     	     	     	
Address	City	State	Zip Code