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Appendix E Transitional Living PlacementsApril 19th, 2017
Is this Site a:□ Subcontractor □ Linkage Agreement □ Agency Site DCFS License Type and #: Expiration Date: Placement Contact Person: Title: Phone: Email: Address:(Street Address not required for Host Home) City: Zip: County and/or Community Area of Placement: Placement cost per night: OR Placement cost per Month: Placement type:□ Scattered Site □ Host Home □ Group Home □ Supervised Apartment □ Other: Population served:□ Males □ Females □ Both Maximum Available daily Capacity of Placement Site: Population served:□ Under 18 □ Over 18 □ Both Additional description of placement option:
