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Provider Profile This service may not be appropriate for every individual. Please work with the regional center service coordinator/case manager and the Interdisciplinary Team to determine the community option that best meets the individual’s unique service needs.

General Information: Name of Home: Parent Company: City/Zip Code : License Number: Service Design:

Regional Center Contact: Contact Person: Phone Number: Fax Number: Email Address:

Provider Information: Director Name: Qualifications: Administrator: Qualifications:

Business Information: Years Experience:

Existing Homes: Specialty Services: Provider Statement:

Staffing Pattern:

Staffing Information:

Training Requirements: Average Length of Service:

Physical Characteristics and Special Features: Sq. Ft.: Lot Size: Bedrooms: Baths: Lay out: Number of ambulatory bedrooms: Number of non-ambulatory bedrooms: Provider Profile Ramps: Guide Rails: Wheel Chair Accessible: Back Yard: Patio: Grass: Garden: Wheel Chair Accessible:

Special Features: Safety Features: Neighborhood Amenities: ( proximity ) select from drop down menu Hospital: Parks: Shopping: Entertainment: Freeways: Places to Worship: Other:

Community Programs:

Volunteer Programs:

Types of Transportation Services: