Thank you for considering Fourth Avenue Homes, Inc. for placement/services.

Fourth Avenue Homes, Inc. strives to provide quality care and support to the individuals that entrust us with their care. We value providing a smooth transition into our homes and will make every effort to place your client. The more knowledge you provide us of your service needs, the better we will be able to help you with placement.

Below is our Admission Information Screening Form that will assist us in reviewing your request for services. Along with your Admission Information Screen Form, please submit the following items in the form or by mail, fax, or email.

Include these items with your form:

  • Current SP/ISP/SPA/IRPA (signed by IDT to include individual)
  • Evaluation(s): psychological, neuropsychological, behavioral, psychosexual, etc.
  • Current medication list
  • Current medical equipment/specialized adaptive equipment info
  • IAPP from previous provider and/or work program
  • ISA (Intensive Services Assessment) from previous provider
  • Any incident reports for last 6 months
  • Any EUMRs for last 12 months (to include required incident reports)
  • Guardianship/Conservator or POA papers signed
  • Criminal history information (including anything pending)
  • Termination letter (if applicable) from provider
  • Any other pertinent information for consideration

What's next?

Once we receive your referral information, we will promptly work to find an appropriate fit based on our available openings that best meet the needs of your client, and match with the others already living in the home. We will contact you once we have determined that we have an appropriate opening. We will arrange tours with you, the person receiving services, and guardian or family member(s).

As an important reminder: Once Fourth Avenue Homes, Inc. has agreed to accept your person needing services, the county of financial responsibility shall notify the host county using form DHS-7418 (6/17). If this client has adult mental health case management, host county concurrence is required prior to placement by the county of financial responsibility.

Admission Information Screening Form

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