Apply for Placement

Are You a Good Fit?

We want our members to thrive in a safe and independent space. To qualify, you must:

Be Mentally Aware

Be mentally able to make daily decisions and manage personal routines.

Self-Reliant

Get in and out of bed or chair by yourself.
Use mobility devices like a cane, walker, or wheelchair safely and independently.
Handle basic daily movements such as using the restroom or preparing simple meals.

Follow Medication Plans

Take your prescribed medications as directed to help maintain your health and stability.

Reliable Income

Have a steady source of income to cover your housing costs.

Examples:
VA benefits
Private Pay
Social Security
Retirement or Pension

Apply Now

24 Hour Turnaround

Broughton’s Refuge is committed to processing your application quickly. You can expect a response or confirmation of the next steps within 24 hours of submission.

Are you a family member referring a client for placement? *YesNo

Are you a caseworker, parole officer, social worker, or other professional referring a member for placement? *YesNo

Agency or Referral Contact InformationPlease complete this section if you are submitting this application on behalf of a potential member.

Name *

Agency/Company Name

Email Address *

Phone *

Relationship to Client *

Health & Functional Status

Required - Upload Client's FilesUpload Client's H&P, Nurses Notes, Discharge Summary Files, Ect. If having problems email needed files to home@openwindowsolutions.com

Drag and Drop (or) Choose Files

Which of the following statements accurately describe your/the client's current mobility and self-care abilities? *Check All That ApplyUse a wheelchairUse a walker, cane, rollaterCan transfer to and from toilet independentlyCan perform basic self-care (bathing, dressing, eating)Capable of responding independently to an emergency situationNone of the Above

Any cognitive or mental health diagnosis? *

Client's Primary Health Diagnosis or Disability *

Client Information

Name *

Date of Birth *00/00/0000

Age *

Phone

Email Address

Anticipated Move-in Date: *00/00/0000

Are you a US citizen? *YesNo

Do you have supportive family or friends nearby? * *YesNo

How long do you think you will stay at one of our facilitates? * *Under 3 Months4-6 Months7 Month to 1 YearOver a Year

INCOME & BENEFITS

What source of income do you have? *Select all that apply *SSISSDIVeterans BenefitsNo IncomeSteady EmploymentPrivate Pay by FamilyPrivate Pay by OrganizationOther

Monthly Income from All Source *

Does client have a payee or representative? *YesNo

Payee or Rep Name

Do you have documentation to verify your income like award letter or pay check stubs? *ie Award Letter, Bank Statement, Check StubsYesNoOther

Upload award letter, pay check stubs, ect

Drag and Drop (or) Choose Files

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