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Program Fact Sheet

Please complete a separate fact sheet for each program.

If you would rather print out the fact sheet and mail it in, click here to download the PDF version.

Please select the office to which you want to send this form:

1. Organization name:
2. Phone:
2a. Web-site address: http://
2b. Email:
3. Program name:
4. Program phone:
5. Program address:
City, state, zip:    
6. Program fax:
7. Pager no.:
7a. Email:
8. Type of program: Residential   Vocational   Respite Care  
Hospital   Special Education  
Other (please describe below):  
8a. Is the program: Locked   Staff Secure   Consumer Independent   Other (please describe below):  
9. Program Description:
10. Type of consumers:
11. Age range:
12. Functioning level:
13. No. of consumers
14. Staff/Consumer Ratio: Days:
Evenings:
Overnights:
14a. Shift times: Days (1st shift):
Evenings (2nd shift):
Overnights (3rd shift):
15. Treatment method / program philosophy / protocols:
16. Does your program use physical intervention for behavior modification?
Yes   No
16a. Will ARBOR staff be required to restrain?
Yes   No
17. If "Yes" to question 16a, what type of physical intervention is required?
TCI   CPI   NVSD   PAC   SOLVE  
Other (please list):
18. Special consumer challenges (i.e. behavioral, medical):
19. Brief job description (job description/competency requirements):
20. Essential skills required MAP (Med-Cert)   CPR   First aid  
Hygiene   Lifting  
List additional skills required:
21. List your authorized contact staff who will be requesting ARBOR's services:
Name:   Title:
Name:   Title:
Name:   Title:
22.

Complete the transportation directions in as much detail as possible by car and public transportation, if applicable. The directions you give are the directions we will give our staff to get to your program. Please give an approximation of miles, landmarks, colors of the building or house, major highways and bus numbers. Please use additional paper if necessary.

Directions by Car: (ALSO, please include landmarks, building description and entrance procedures. Example: "Program is a white house w/black shutters next to a post-office. ARBOR Staff should ring doorbell and wait to be let inside by Program Staff."

Is parking available? Yes   No  
Where?

Directions by MBTA (bus and/or subway):
23. Is an orientation manual on the site for our staff? Yes   No
Where?
24.

What are the procedures in an emergency situation?
25. Who do we call?
Phone:  
Pager:
26.

Where are the emergency procedures located on site?
25. Fact Sheet completed by: Name:  
Title: