Program Participant Placement Questionnaire Facility Name * Name of Housing Director * First Name Last Name Phone * (###) ### #### Email * Facility Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referral Request Details Number of Open Beds * Date Beds Need to Be Filled * MM DD YYYY Preferred Move-In Date(s) * MM DD YYYY Program Type * Level of Structure Offered * High Structure Moderate Independent Eligibility Requirements * Support Services Available (check all that apply) * Transportation Case Management Meals Provided Medication Support Other Does Participant Need Assistance with ADLs (Activities of Daily Living) * Yes No If "Yes" Please Select One the Following 100% of ADL Assistance Needed 75% of ADL Assistance Needed 50% of ADL Assistance Needed 25% of ADL Assistance Needed Do You Provide Housekeeping or Laundry Services * Yes No Is There Supervision available 24/7? * Yes No Do You Allow Home Health Aides or Visiting Nurses for Housing Participants? (Live-ins) * Yes No Are Pets Allowed? * Yes No Is Smoking Allowed? * Yes No Are Visitors Allowed? * Yes No What Is Your Participant Fee? * Is There A Community Fee Required? * Yes No Are Utilities Included? * Yes No Do You Have 24/hour Surveillance? * Yes No Do You Accept All Pay Methods? * Do You Have 24/hour Surveillance? * Yes No Do You House Returning Citizens? * Yes No Do You Require Background Checks? * Yes No What is Your Preferred Way to Receive Referrals? * Email Phone What unique features or benefits does your housing program and facility offer that you'd like agencies or potential participants to know about? * Are there any specific challenges you have had with previous referrals that we should avoid when matching you with participants? * Is There a Specific Demographic You Prefer to House? * Yes No Is There a Particular Demographic You Are Not Equipped to House at This Time? Which Age Group is Your Facility Prepared to Accommodate? * Do You Have Any Specific Criteria, Preferences, or Expectations for Participants Entering Your Program? Ambulatory Medication Compliant Able to Follow House Expectations Required to Independently Manage their Own ADL's Other Are There Specific Behaviors That Would Not Be Accepted In Your Housing Program? * Additional Participant Preferences You Would Consider? Referral Fee Agreement Housing Program Director agrees to pay a one-time Placement Service Fee to Madison Rose Solutions, LLC of $300 per Referral upon acceptance of housing participant(s).Invoice will be issued upon submission of this form. Payment is due prior to referral delivery. No referral will be made until payment is received. By submitting this form, the requesting facility (you) confirms that all information provided is accurate and that they agree to Madison Rose Solutions' referral terms and fee structure. Madison Rose Solutions does not guarantee long-term placement post-referral. I agree to the terms of this agreement * Yes No By Clicking "Yes", I confirm my consent and acknowledge this action as my electronic signature on the agreement and request form. * Yes No Looking for ready-to-use housing forms, agreements, or PDF-formatted templates? Explore our collection of professional documents available for purchase. We’ll share the link with you! Thank you!
