test "*" indicates required fields Type of Residential Need or Vacancy* SLP 1 SLP2 CTH 1 CTH 2 CRCF ICF PRTF Residential Tier willing to accept*Funding accepted – (Waiver, State funded, etc.)*Is provider accepting High Management consumers?* Yes No Willingness to accept someone WITHOUT SSI* Yes No County of Vacancy*Rural or Metro location*Gender Preference of the Home* Male Female Coed Age of consumers where vacancy is located*Age of consumers provider is interested in*ADL requirements of consumer*Willing to accept HASCI consumer* Yes No Staffing Level available in the home (1:1, 1:4, etc.)*Activity Level of Consumers in the home (High, Low, Sedentary)*Accessibility of Home (Ramps, Roll in Shower, Accessible Bathroom, Accessible Areas of Home)*Accept Behavioral Issues?* Yes No Explain MoreAccept Elopement Issues?* Yes No Explain MoreAccept people with Law Enforcement History?* Yes No Explain MoreAccept people who are Judicially committed?* Yes No Explain MoreAccept Consumers requiring Evacuation Assistance?* Yes No Explain MoreOther important information about the house and people living in the homeContact Person for the agency where vacancy is located* First Name Last Name Contact Email for Person handling the vacancy* Contact Phone number for the person handling the vacancy* "*" indicates required fields Initials of ConsumerType of Residential Approved* SLP 1 SLP 2 CTH 1 CTH 2 CRCF ICF PRTF Level/Tier Approved*Current County of Residence*Legal Guardian Present?* Yes No Explain MoreEligibility Info (ID/DD, Autism/HASCI)*Male/Female/Identified as Other*Age of consumer*Activity Level of Individual (High, Low, Sedentary)*Accessibility Needs*Behavioral Needs*Elopement history/issues* Yes No Explain MoreLaw Enforcement History* Yes No Explain MoreJudicial Commitment* Yes No Explain MoreDSS Involvement* Yes No Explain MoreHistory of Previous Placements* Yes No Explain MoreCurrently in Alternative placement* Yes No Explain MoreEmergency Evacuation Needs (full assistance, partial assistance, no assistance) (comment section)*Name of Agency Supporting Individual*Contact Person for the Agency Supporting Individual* First Name Last Name Email Address for Agency Contact Person Supporting individual* Phone number for Agency Contact person supporting individual*
