Referral Form

NEW ILF Sign Up

This form is used when requesting to partner with us to accept referrals. We will contact you to set up a phone call to find out more about your ILF.
- Name
  
  First NameLast Name
- Email
- Company/Entity Name
- How did you find us?
- Are you the sole owner of the ILF?
- Website
- Best Phone Number
  Format: (000) 000-0000.
- Do you have any photos you want to share of your facility to give us a better view?
  
  Cancelof
- What is your minimum cost per bed?
  Just average as of today
- Do you require a deposit?
  We will go over this on the call in more detail
- Please tell us more about your ILF:
  What inspired to start? Types of placements your prefer, location details, etc.
- Are you willing to pay a referral fee?
  It's free to join our partner program, but we typically receive a placement/referral fee once they actually sign up.
- Select all applicable requirements or areas your willing to accept for the Individual referred (check all that apply)
  
  They can cook for themselvesThey can clean up after themselvesThey must self administer their own medicationSustainable employmentI am open to most situationsMust be over 18Must be employedMust receive SSI or regular incomeThey can receive income from a grantLight DepressionLight GriefCourt InvolvementCase worker involvement18 year old coming from Foster CareWoman Only FacilityMen Only FacilityWoman & ChildrenCo-ed Facility18-25 FacilityOther
- Select all applicable that you offer at your facility or some that may apply (check all that apply)
  
  All utilities are includedHeating and air conditioningAll cleaning supplies are includedAll food is suppliedAll food is meal preppedPhone for emergenciesCurfew ScheduleToiletries or TowelsRefrigerator/Stove is supplied, but they cook their own foodBibles providedInternet / WIFIComputersEducation Books/Small LibraryTV in Living RoomTV in RoomsFully Furnished FacilityOutdoor FurnitureMonthly Check insIndependent living skills coachingTransportation optionsNutrition InformationAppointment SettingWeekly trash pick upCareer and Education InformationOther
- Should be Empty:

NEW ILF Sign Up