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Group Living Services (GLS) Grouping Chart - Private, Public, Canadian, Network
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Organization
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Org ID #
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City
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State/Province
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Instructions
Indicate the average number of residents from the previous month assigned to each group home, unit, or cottage. A "group" for this purpose is the unit of residents living together in one place. Make additional copies as needed.
Name of Cottage, Unit, or Group
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# of Residents (Male)
Your answer
# of Residents (Female)
Your answer
Staff : Resident Ratio
Your answer
Type of Facility
Apartment
Single Family Home
Multi-unit Building
Cottages
Other:
Clear selection
Function or Purpose
Adm./Diag
Gen. Prog.
Secure Unit
Indep. Living/Transit
Other
Clear selection
Licensed Capacity
Your answer
Name of Cottage, Unit, or Group
Your answer
# of Residents (Male)
Your answer
# of Residents (Female)
Your answer
Staff : Resident Ratio
Your answer
Type of Facility
Apartment
Single Family Home
Multi-unit Building
Cottages
Other:
Clear selection
Function or Purpose
Adm./Diag
Gen. Prog.
Secure Unit
Indep. Living/Transit
Other
Clear selection
Licensed Capacity
Your answer
Name of Cottage, Unit, or Group
Your answer
# of Residents (Male)
Your answer
# of Residents (Female)
Your answer
Staff : Resident Ratio
Your answer
Type of Facility
Apartment
Single Family Home
Multi-unit Building
Cottages
Other:
Clear selection
Function or Purpose
Adm./Diag
Gen. Prog.
Secure Unit
Indep. Living/Transit
Other
Clear selection
Licensed Capacity
Your answer
Total number of individuals referred to the organization's group home(s) for placement this year
Your answer
Of the above number, how many individuals were actually accepted/placed in the group home(s):
Your answer
Average length of stay (days) of the total population in the last year:
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