Organization Information
Organization Name
Organization Type
Point of Contact Name
Title/Role
Phone Number
*
Email Address
*
Website (If applicable)
Address
Physical Address
City
State
Postal code
Service Area or Geographic Reach
Preferred method of contact
Population Served
What client populations do you primarily serve?
How many clients per month typically need housing placement?
What is the average age range of your clients?
What is the most urgent housing need you currently face?
Client Eligibility
Are your clients typically receiving income or benefits (SSI, SSDI, VA, etc.)
Yes
No
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Do you conduct background checks or expect the housing provider to do so?
Are there any specific conditions that may require specialized housing?
Do you have staff that support your clients post-placement?
Referral Process
Do you currently refer to housing providers?
Yes
No
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How many?
What is your ideal turnaround time from referral to placement?
What documents do you typicall provide with a referral?
Would you like to receive updates when new beds become available?
Yes
No
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How do you prefer to send referrals?
Additional Info
What challenges have you faced in referring clients to housing?
What would an ideal partnership with a group home look like to you?
Would you like to schedule a tour of one of our homes or speak to a placement coordinator?
Please upload any relevant materials (flyers, referral forms, program info, etc.)