Personal Information

Please fill out as much information as possible. This will ensure placement is fast and efficient.

Type of Waiver *

CADI Waiver

DD Waiver

BI Waiver

Elderly Waiver

Private Pay

Specific Option *Select

Timeframe Needed *

IMMEDIATLEY

1-2 Weeks

1 Month

Other

Type of Housing Desired *

18+

55+

Pets Accepted

Wheelchair Accessible

If multiple options will work, Please list which of above you prefer.

Full Name or Initials *

Date of Birth Pick a date

PMI Number

Phone Number

Email Address

Medical Equipment, Devices, Adaptive Aides, Technology, Specific Medical Needs *

Guardian Status *

Self

Private

Public

Under Commitement

Current Living Situation *

Own housing: Lease, Mortgage or Roommate

Service Provider: Foster Care or Group Home

Hotel Motel

Jail/Prison/Junvenile Detention

Family/Friends due to Economic Hardship

Emergency Shelter

A place not meant for Housing

Other

Mobility

Some of our homes have rooms that are accessible, but not to the entire house, just one floor. Other homes are made accessible with the use of chair lifts. Please answer the following questions so we can provide you with a list of the most appropriate settings for your individual’s specific needs

Does this person have mobility concerns? *

Yes

No

Does this person use OR could they use any of the following to assist with mobility/accessibility? (Cane, Walker, Wheelchair, Scooter, Chair lift for stairs, Hoyer Lift) If yes please list what is used below.

Would they be open to moving into a home if they only had access to one floor of the home, due to the limited accessibility of the home?

Yes

No

Team Contact

*Please Include Name, Company Name, Best Contact Number & Email Address in the Spaces Provided*

Waiver Case Manager: Company Name, Best Contact Number & Email Address *

Referring Party: Company Name, Best Contact Number & Email Address*If different from Waiver Case Manager

Legal Representative or Guardian: Company Name, Best Contact Number & Email Address

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