• Premier Host Homes — Secure Member Referral

    Complete this multi-page referral with test information only (TEST MODE) to help our placement team understand needs, preferences, and timing.

  • Case Manager / Referral Source

  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Date of Referral*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Member Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender Identity
  • Current Living Arrangement*
  • Has Guardian?*
  • Format: (000) 000-0000.
  • Guardian Is Legal Decision-Maker
  • Waiver Type*
  • Desired Transition / Move Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Urgency / Timeframe*

  • Placement Request & Preferences

  • Willing to Consider Other Areas?*
  • Preferred Host Home Provider Gender
  • Preference Regarding Children in the Home
  • Preference Regarding Other Adults in the Home
  • Pet Preferences, Allergies, or Fears

  • Daily Support Needs

  • Medical & Behavioral Supports

  • Medical conditions or diagnoses relevant to placement
  • Current medications summary available?*
  • Has the member got any known allergies?
  • Seizure history
  • Mobility or fall risks
  • Medical equipment or assistive devices
  • Behavioral health supports needed
  • Aggression or safety risk
  • Self-injury risk
  • Elopement or wandering risk
  • Property destruction risk
  • Sexual safety or boundary concerns
  • Substance-use considerations
  • Current Behavior Support Plan in place?

  • Current Services & Natural Supports

  • Day Program / Employment / School Status*

  • Documents

  • Document categories to include*
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  • Upload a File
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  • Upload a File
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  • Upload a File
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  • Upload a File
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  • Additional Information & Consent

  • Acknowledgement*
  • Should be Empty: