Shared Living Application

Date

Name

Social Security No.

Home Address

Home City/State

Home Zip Code

Mailing Address

Mailing City/State

Mailing Zip Code

Telephone

Cell Phone

Work phone

E-mail Address

How long have you lived at this address?

If less than 3 yrs. Please give previous address.

Do you have reliable transportation? Yes No

Do you have a valid driver’s license? Yes No

Driver’s License #

Current Occupation

Number of hours worked weekly:

What are your plans regarding your current employment, if you become a Provider?

Do you: Own Rent

What kind of home? Single Family Mobile Home

Other

Please briefly describe your home.

What changes would have to be made in your home to prepare for the individual?

Adults living in the home (name, DOB, Social Security Number, relationship to you):

Children living in the home (name, DOB, relationship to you):

Do you have pets? If so, please list each including the type, breed, and indicate if documentation of vaccines is available:

What is the frequency of use of alcohol in your house by you or others? Never Monthly Weekly Daily Hourly

What is the frequency of use of tobacco in your house by you or others? Never Monthly Weekly Daily Hourly

How did you learn about Support Solutions and this opportunity?

Why are you interested in becoming a Provider?

Do you have any limitations that would restrict your ability to provide services 24 hours a day, seven days a week? (Physical, medical, commitment to others etc.)

What is the reaction of other family members to your decision to become a Provider?

Please describe your experiences in the human services field including education and work with individuals with disabilities.

What are your hobbies and interests?

Please describe the characteristics of the person you would be willing to share you home with. (Male/female, activity level)

In what way would you be willing to provide support? (Personal care, lifting, challenging behavior etc.)

How would you help this individual become involved in the community?

Would you support an individual with a different lifestyle than yours? Such as, religion, sexual preference, culture etc.

What are your expectations and reservations on becoming a Provider?

Please provide any other information you think would be helpful.

Are you 25 years of age or older? Yes No

Please provide at least 2 professional References

Name

Telephone

Address

Affiliation

Years Known

Name

Telephone

Address

Affiliation

Years Known

Name

Telephone

Address

Affiliation

Years Known

Please provide at least one personal reference

Name

Telephone

Address

Affiliation

Years Known

Name

Telephone

Address

Affiliation

Years Known

Name

Telephone

Address

Affiliation

Years Known

School Name

Address

Years Completed

Diploma or Degree

School Name

Address

Years Completed

Diploma or Degree

School Name

Address

Years Completed

Diploma or Degree

School Name

Address

Years Completed

Diploma or Degree

Please list other training or certifications (Description, Trainer/School, Date)

Please describe any other training or experience relevant to contracted services

Employer Name

Telephone

Dates Employed - From: To:

Please describe duties and responsibilities

Employer Name

Telephone

Dates Employed - From: To:

Please describe duties and responsibilities

Employer Name

Telephone

Dates Employed - From: To:

Please describe duties and responsibilities

Employer Name

Telephone

Dates Employed - From: To:

Please describe duties and responsibilities

Do you have legal right to reside and work in the U.S.? Yes No

Have you ever pled Guilty, or No Contest to or been convicted of a crime? Yes No

If Yes, Please explain:

Have you ever been administratively determined by a federal, state, or local government agency to have committed abuse or neglect? Yes No

If Yes, Please explain:

What, if any, is your experience working with children/adults with developmental disabilities? Yes No

If Yes, Please explain: