Facility Information
Name
Address
Phone

Facility Amenities		How Many?
Do You Have Crisis Stabilization Beds in Your CRF?	Yes   No
Do You Have Transitional Residential Beds?	Yes   No
Are You Licensed to Operate a Child Development Program?	Yes   No

		Number			Other
		M	F	M/F	Live-in Staff	Rotating Staff	Other
Community Residence Facility (CRF)
CRF/MH/Supported Residence
CRF/MH/Supported Rehabilitative Residence
CRF/MH/Intensive Residence
CRF/Halfway House
Group Home for Mentally Retarded Persons

Business Owner Information
Name
Address
Phone
Social Security Number
Residence Director Information
Name
Address
Phone
Birthdate (mm/dd/yy)
Social Security Number
Highest Level of Education Completed

Give three references (not relatives) who have known the Residence Director at least three years and have knowledge of his or her experience in working with people requiring assistance and supervision.

Reference 1
Name
Address
Phone
Reference 2
Name
Address
Phone
Reference 3
Name
Address
Phone

Signature(s): (Include Maiden Name, If Applicable)

  __________________________   Social Security Number:

  __________________________   Social Security Number:

  __________________________   Social Security Number:

Return this form to:

Department of Health
Health Regulation Administration
Child and Residential Community Facilities Division
825 North Capitol Street, NE
Second Floor
Washington, DC 20002

Phone: (202) 442-5929
Fax: (202) 442-4831
or (202) 442-9430