Shared Living Provider Application

Complete the Shared Living Provider application by providing accurate information, attaching necessary documents, and reviewing your application to ensure the best match with individuals needing your care.

Driver's License Number *

Highest Level of Education Completed

Are you currently working with another human service agency?

Yes

If yes, please list the agency

Who referred you to our agency? Reference name and phone number

Why are you interested in taking an individual with disabilities into your home?

Please list any certifications that are valid in the last year pertaining this scope of work

Describe your experience in detail, working with individuals with physical or intellectual disabilities (please do not use names or personal information when detailing your experience)

Who is your current or last employer? What is your job title and brief description of your duties?

Have you been convicted of a crime other than speeding?

Yes

If you answered YES, you MUST list the date of conviction, county/state in which the conviction occurred and the type of conviction(s). Please note that a conviction is not necessarily a disqualification for hiring.

Please include a brief description of the conviction including what the conviction was for, what happened and who was involved? Use separate sheet of paper if need additional space for additional convictions.

Are you willing to support a male?

Yes

Are you willing to support a female?

Yes

Are you willing to accept an emergency placement (which has no advance notice, quick or same day)?

Yes

Are you willing to work with an individual who has a vision impairment including blindness?

Yes

Are you willing to work with an individual who has a hearing impairment including deafness?

Yes

Are you willing to work with an individual who does not communicate with words?

Yes

Are you willing to work with someone who requires constant supervision in the community?

Yes

Are you willing to work with someone who requires physical assistance for things such as bathing, toileting, brushing teeth and utilizing adaptive devices?

Yes

Are you willing to work with someone who drinks alcoholic beverages, tobacco or vape use, marijuana, or other street drugs, has alone time with significant other?

Yes

Are you willing to work with someone who yells, name calls, swears, make threats?

Yes

Are you willing to work with someone who hits, kicks, bites, spits?

Yes

Are you willing to work with someone who breaks property, throws things?

Yes

Are you willing to work with someone who elopes?

Yes

Are you willing to work with someone who hurts self (bangs head, cuts self, skin picking, etc.)?

Yes

Are you willing to work with someone who has poor sexual boundaries (masturbation in public areas of the home or community, poor boundaries with others)?

Yes

Are you willing to work with someone who displays sexually inappropriate behaviors (requires constant supervision in the community and with/around children)?

Yes

Are you willing to work with someone who steals/theft of property?

Yes

If you would like to provide additional information or explanation to any of the above questions, please use this area:

Describe your home including number of bedrooms and how many are in use:

Do you have any pets in your home?

Yes

If yes, describe the pets in the home, including if they are vaccinated and licensed:

Does anyone in the home smoke?

Yes

Please list every individual that resides in your home, even if its temporary or irregular. Please list individual’s age and relationship. All household members 18 and are we required to complete a background check. Household members 13 – 17 are required to complete APS and CPS background checks.

Are the people in your home willing to submit to background checks and/or training as it applies?

Yes

Are you serving any other individual in your home at this time? This includes foster care, kinship care, Shared Living, etc.?

Yes

If yes, how long have you supported the individual(s)?

List any specialist training you have including Mandt, CPR/First Aid, Med Aide, etc. Please provide a photocopy of all certifications.