EOHHS New Group Home Request Form 7.6.20.docx
DOCX document 41 KB Posted
- Solicitation number
- BD-21-1022-DMH08-8220A-53630
- Issued by
- Massachusetts
About this file
The document is a New Home Request Form from the Massachusetts Executive Office of Health and Human Services (EOHHS) for all proposed homes for EOHHS agency state-operated or provider-operated residential programs. The form must be submitted by the requesting agency and includes details on the location, setting, population to be served, and neighborhood characteristics of the proposed home. The state and local contract opportunity is for the Massachusetts Department of Mental Health (DMH) to establish a pool of qualified providers from which DMH Areas can purchase Site-Based Respite and/or Mobile Respite Services on an as-needed basis.
The form collects information such as the EOHHS agency, number of individuals to be served, setting, population profile, neighborhood amenities, and other details relevant to supporting the quality of life and integration into the community for the proposed population. The state and local contract opportunity is an Amended and Restated Respite Services - Master Agreement Request for Applications, seeking to establish a provider pool for site-based and mobile respite services.
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Text version
EOHHS Log Number: Click here to enter text.
EOHHS Siting Guidelines and Operational Procedures: New Home Request
To be submitted to EOHHS Facilities Office for all proposed homes for all EOHHS agency state operated or provider operated residential programs. Form must be submitted by the requesting agency to ehs.grouphomes@massmail.state.ma.us.
Date: Click here to enter a date.
EOHHS agency: DMH
EOHHS agency contact: Jay Potter
Vendor contact (if applicable): Click here to enter text.
Operator of the home (provider name or state operated):Click here to enter text.
Building owner: Choose an item.
Number and street: Click here to enter text. Apartment number: Click here to enter text.
City/town and zip code: Click here to enter text.
Status (proposed; contingent offer in process; etc): Click here to enter text.
Number of individuals to be served/ occupy the home: Choose an item.
Setting (shared living; group home; independent apartment; supported housing): Click here to enter text.
Brief profile of the population to be served (for example, individuals with intellectual and/or developmental disabilities, people with brain injuries, people with mental illness, individuals in Teen Programs, etc): Click here to enter text.
Other useful information (for example: is this a relocation/replacement? was this previously approved and if so what was the original log number? is this an apartment complex?): Click here to enter text.
Please describe general characteristics of the neighborhood (provide brief narrative of area amenities that are relevant to support the quality of life and integration into the community for the proposed population): Click here to enter text.
In the following section, please identify specific services in the neighborhood that can be accessed within 5 miles of the program:
Shopping opportunities, including food and personal items: Click here to enter text.
Parks and recreational activities, including, if appropriate to the population, walking and hiking trails: Click here to enter text.
Health care services: Click here to enter text.
Places of worship: Click here to enter text.
Public transportation, both for residents, if applicable, and for staff and visitors to the home: Click here to enter text.
Social activities, entertainment and cultural enrichment (including libraries, theatres, and museums): Click here to enter text.
Other considerations (such as longstanding community connections, friends, and relatives in the area): Click here to enter text.
Form filled out by: Click here to enter text.
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.
Last edited: August 2019
File details come from the government source that posted it. Updated .