Form

Thank you for your interest in Quality Life Assistant. We have a few simple questions for you to answer in order for us to provide you with a cost specific to your organization.

General Information

Agency name*

Your first name*

Your last name*

Email*

A brief description of your organization and the services that you provide*

Please provide the number of employees in the following positions

Executive Directors*

A person who is hired by the Board of Directors, and is directly accountable to the Board of Directors. Executive Director is responsible for the day to day operations of the Agency which include: the care and well-being of the residents, human and financial resources, and property management. This person negotiates funding with the Government, and reports on operation of the Agency to the Government (both financial and programmatic).

Program Coordinators*

The management staff who takes the lead role in the process of admission of a new resident, and is responsible for development, monitoring, and evaluation of Care Plans and Person Centered Plans for each resident. The Program Coordinator trains, supervises and supports staff to work with the residents. This staff collects, reviews, interprets, and summarizes data submitted by the Team Leaders and Direct Care Workers which include: incident reports, medical appointment reports, seizure activity reports, and daily activities reports.

Team Leaders*

Carries out Care Plans and Person Centered Plans prepared by the Program Coordinator. Supervises Direct Care Workers, and also directly works with residents. This person is responsible for residents living in the home which he/she supervises.

Direct Care Workers*

Care worker / frontline staff person who provides direct support for residents/participants.

Number of participants (those to which the organization provides services)

Total number of participants*

Number of participants in the following programs

Homes/Residences

Day Program

Supported Living Program

Supported Employment Program

Other

Program type

Number of participants

Do you plan or anticipate for Agency growth over the next 1-2 years?*

This includes opening new homes, expanding services, hiring additional staff, etc.

Additional notes and comments

Disclaimer:
This information is kept strictly confidential and is used solely for providing a quote that coincides with your agency’s specific needs.