AFL Inquiry Form
1. Your Name:
*
First Name
Last Name
2. Email Address:
*
example@example.com
3. Submission Date:
*
-
Month
-
Day
Year
4. Have you ever been convicted of a crime?
*
Yes
No
5. Physical Address
*
Street Address
Street Address Line 2
City
County
Zip Code
6. Phone Number:
*
-
Area Code
Phone Number
7. Are you a current DSP with Charles Lea Center?
*
Yes
No
8. Have you ever worked for Charles Lea Center?
*
Yes
No
9. Describe yourself, your IDD experience, your strengths and what you are looking for. (Reimbursement rates for AFL services are not provided until client match is made)
*
10. Name and ages of adults who live in the home?
*
11. Name and ages of children (0-17) who live in the home?
*
12. Type of residential dwelling
*
House
Townhome
Mobile
Modular
Apartment
13. Does the contractor feel most comfortable serving male or female clients?
Male
Female
Either
14. Is the home 1 story, 2 story, split level?
1 Story
2 Story
split level
15. Are the available bedroom(s) on the first or second floor?
First floor
Second floor
Other
16. How many bedrooms are in the dwelling?
*
Please Select
1
2
3
4
5
6
7
17. How many bathrooms are in the dwelling?
*
Please Select
1
2
3
4
5
6
7
18. Is there a clean, functioning bathroom that includes adequate ventilation for the potential client to use?
*
Yes
No
19. Would the client have adequate privacy (adequate space, door on bedroom and bathroom, workable lock on inside doors)?
*
Yes
No
20. Is there adequate lighting in bedrooms, bathrooms, stairways, halls, exits, etc.?
*
Yes
No
21. Are their steps inside the home, to the front and back doors, in the garage?
*
Yes
No
22. If yes, how many for each?
23. What is located nearby the home (landmarks, bus lines, neighborhoods, schools, highways, shopping centers etc.)?
*
24. Have you ever been an AFL before? If yes, explain.
*
25. What is your target client move in date? Choose today's date if you are prepared immediately.
*
-
Month
-
Day
Year
Date
26. Are you willing to provide overnight services in the Client's home?
*
Yes
No
27. Are you willing to provide Respite or Emergency Respite in your home for Charles Lea Center's clients?
*
Yes
No
Save
Submit
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