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

Print Applicant Name:      

	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 an applicant’s case file. 	
     	
Print Name of Mental Health Professional 	
     	
License/Qualification of Mental Health Professional 	
     	     	
Telephone Number 	Fax	
     	     	                     	
Address	City	State	Zip Code	
	     	
Signature of Mental Health Professional 	Date	
				
Return this form to the following address: 	
     	
Print Name of Housing Agency 	
                                                                                                                                                            	
Address	City	State	Zip Code