Prospective Partner Program Fact Sheet

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Program Fact Sheet
Please complete a separate fact sheet for each program within your agency in which Arbor's services will be utilized. The Program Name you list will be used for invoices, requesting staff, and conveying information to Arbor's field staff, in conjunction with your Organization/Agency name.

The use of the following information is intended to help Arbor Associates professionals meet their obligations. Any information that you provide will be helpful in placing appropriate employees and is appreciated. Information can be updated in the future as needed. Thank you.

General Program Information

* Indicates required field

Organization / Agency Name *

Program / House Name *

Program Street Address *

Line 1

Line 2

City

State

Zip Code

Country

Program Phone Number *

Program Fax *

Website *

Primary Contact *

First

Last

Primary Contact's Title *

Primary Contact's Phone *

Primary Contact's Email *

After-Hours Phone Number *

Vital for communication regarding call-outs, tardiness, or other unforeseen circumstances.

Emergency Contact *

First

Last

Emergency Contact Phone *

Emergency Contact Email *

Please provide the name and contact information of at least one other person from your organization who is authorized to request Arbor staff and/or discuss any issues:

2nd Contact's Name *

First

Last

2nd Contact's Email Address *

3rd Contact's Name *

First

Last

3rd Contact's Email Address *

2nd Contact's Title *

2nd Contact's Phone Number *

3rd Contact's Title *

3rd Contact's Phone Number *

Timesheet Approver's Name *

First

Last

The designated Time Sheet Approver MUST be listed above as a contact. It does not have to be the same person who will be billed for services rendered. Arbor field staff (aka "Associates") who work at your program are required to complete Arbor timesheets on a weekly basis. Before being paid for hours worked, their timesheets must be approved by your organization by the weekly due date via Arbor's online portal. Please choose a Timesheet Approver who will be able to confirm or refute the Arbor Associate's timesheet of hours actually worked. Should you have any questions about whom to assign as the Timesheet Approver, please contact us.

Billing Information

Contact Name for Invoices: *

First

Last

Billing Contact's Title *

Billing Phone Number *

For questions regarding invoices.

Billing Email Address *

Email where invoices and billing communication should be sent.

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Program Details

Program Type(s) *

Residential - Group Home Residential - Independent Living Residential - Support in Family Home Personal Care (Hygiene, feeding, etc.) Day Program / Vocational Staff Secure Emergency Shelter / Respite Transitional Housing Foster Care / Adoption Agency Teen Pregnancy / Parenting Education Hospital Special Education Early Education / Child Care Other

Other: *

Program details / description *

Include any details that would be helpful to Arbor staff such as mission, special consumer challenges, treatment method, etc.

Staff to Consumer Ratios *

Consumer Challenges / Population(s) *

Intellectually / Developmental Disabled Physically Disabled / Handicapped Mental Health / Behavior Challenges Substance Abuse Dual Diagnosis Physical and/or Sexual Assault Victims Physical and/or Sexual Assault Perpetrators Homelessness / Housing Insecure Refugee / Immigrant ESL - If yes, indicate native language(s) None Other

Please detail any "other" in program description field or under program details/description.

Other / Details *

Consumer Age(s) *

Infant - 24mth Toddler Preschool-Kindergarten Elementary School Age Adolescent / Teen Adult (18+) Elderly

Consumer Age Range *

Consumer Gender(s) *

Co-Ed Female Only Male Only Transgender

Staffing Requirements & Information

Job Description and Expectations for Arbor Staff *

Is an orientation manual on the site for our staff? *

Yes No N/A

Dress Code for Arbor Staff *

General emergency procedures *

Will Arbor Staff be required to restrain or have intervention certification? If yes, type: *

TCI CPI HWC Other N/A

Other *

Other Skills Required for Arbor Staff (All have First Aid/CPR) *

MAP (Med-Cert) Hygiene Lifting / Ambulatory Early Education Certified Administrative / Office Skills Elder Care Other

Other (details) *

Will Arbor Staff be required to complete program-specific certification or training? *

Yes No

(example: hospital orientation)

Gender requirements for Arbor placement *

None Yes - place female staff only Yes - place male staff only Depends on shift / current population

Getting There

Are GPS-enabled devices accurate for driving directions? *

Yes No

If not, provide driving directions below.

List any useful landmarks or details about location. *

Details such as "white house on corner of Street X and Street X".

Is On-Site Parking Available? *

Yes No

Is program available via public transportation? *

Yes No

If Yes, Public Transportation details *

Route, train, bus #'s, etc.

Fact Sheet completed by:

Name *

First

Last

Date *

Please click gray "Submit" button below when finished. Thank you!

Privacy policy. This privacy policy sets out how Arbor Associates uses and protects any information that you give Arbor Associates when you use this digital form. Arbor Associates is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this digital form, then you can be assured that it will only be used in accordance with this privacy statement. *Security on our intranet is treated seriously. We undertake security steps, including SSL technology, to protect customer account information and data transmissions.

Click Here To Submit Form

Massachusetts:
Auburn: 508-792-3444
North Andover: 978-651-9660
Malden: 617-227-8829
Wellesley: 781-304-8220
Rhode Island:
Cranston: 401-521-1910
Corporate:
617-227-8829, 888-272-6767

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