9. EOHH New Group Home Request Form~1.docx

EOHHS Siting Guidelines and Operational Procedures January 2, 2017 EOHHS NEW HOME REQUEST, Page 1

To be submitted to the Director of the EOHHS Facilities Office for all current and/or proposed homes for all EOHHS’ agencies, state operated or provider operated residential programs.

Date _________________________________________ (2016 will be used for all existing homes; otherwise the date the address is being submitted for consideration)

EOHHS Agency: _____________________________________________________________

EOHHS Agency Contact: _______________________________________________________

Operator of the home: (provider name or state operated) _________________________________

Address of home Street and number: ______________________________________________________

City/Town, Zip _________________________________________________________ (Including street address, city/town, and zip code)

Status: (current; proposed; sale in process; pending licensure, in response to RFR, etc) ______________________________________________________________________________ Number of individuals to be served/ occupy the home_________________________________

Setting: Shared Living; Group Home; Independent Apartment; Supported Housing ______________________________________________________________________________ Brief profile of the population to be served: (for example, Intellectual Disabilities, Developmental Disabilities, Mentally Ill, Brain Injured, Teen Program, Children or Youth Programs.)

Other Useful Information: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EOHHS RESIDENTIAL HOME ADDRESSES ARE CONFIDENTIAL AND ARE EXEMPT FROM DISCLOSURE UNDER THE MASSACHUSETTS PUBLIC RECORDS LAW. THE INFORMATION SUBMITTED PURSUANT TO THIS FORM SHOULD NOT BE SHARED EXCEPT AS PROVIDED IN THIS FORM This form once completed is to be sent to the Director of the EOHHS Facilities Office with a copy to the Director of the Interagency Council on Housing and Homelessness EOHHS NEW HOME REQUEST, Page 2

GROUP HOME SITING CONSIDERATIONS

Agency _______________________________ Date _________________________ Agency contact __________________________ Phone Number ________________ Vendor contact if applicable ________________ Phone Number ________________

Proposed location _________________________________________________________ Building owner (please check one)

· State owned _______

· Vendor owned _______

· State leased _______

· Vendor leased _______

Population profile _________________________________________________________

Neighborhood advantages:

· Residential neighborhood (please provide description):

· Please identify stores and other services nearby:

· Please identify parks and recreational activities nearby:

· Please identify businesses and health care services nearby:

· Please identify places of worship nearby:

· Please identify public transportation nearby:

Other considerations:

Form filled out by ________________________________________________________