Business Information

Business Name

Owner/Administrator Name

Email Address *

Phone Number *

Website (If applicable)

Address

Physical Address

City

State

Postal code

Number of Properties Operated

How long have have you you been in operations?

Are you licensed or certified?

Please Specify

Do you have liability insurance?

Home Capacity & Setup

Total number of beds available across all homes

Are you currently accepting new tenants?

Which locations currently have open beds ?

Is your home(s) wheelchair accessible?

Room Types Available (check all that apply)

Do you provide meals?

Which meals?

Do you offer transportation to clients?

Tenants Criteria

Which populations do you currently serve?

Do you accept clients with criminal backgrounds?

List Exclusions

Do you accept clients with active substance use issues?

Are there mental health conditions you cannot accommodate?

List the type of mental health conditions

Do you accept clients with pets or service animals?

Payment & Referral Info

What sources of payment do you accept? (SSI, VA, self-pay, agency-sponsored, etc.)

What is your monthly rent per client?

Do you charge any deposits or intake fees?

Please specify amounts

What documents do you require for intake?

Preferences & Communication

What is your ideal client profile?

How soon can you accept a client after receiving referral?

Would you like to receive notifications when new tenants are available?

Preferred method for receiving referrals (text, email, phone, portal)

Do you want to be listed in our partner directory?