Home Care/Foster Care Provider Questionnaire

This is not an application for employment.

Bolded fields are required.

I am interested in learning more about becoming a...
Home Care Provider (adults)
Foster Care Provider (children/adolescents)
Home Care Provider (adults) or Foster Care Provider (children/adolescents)

I am interested in providing servies in the state of
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

How did you learn about us...
Newspaper Ad  Flyer  Employment Agency
Employee/Provider  Internet  Other

Personal Information

Name

Would you consider moving for placement?
Yes  No

Have you lived in the state in which you are interested in providing services for seven years or more?
Yes  No

If no, list the states you have lived in during the last seven years.
Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Ethnicity
White (not Hispanic or Latino) Hispanic or Latino Black or African American (not Hispanic or Latino) American Indian or Alaska Native Native Hawaiian or Pacific Islander Other

What languages other than English (including American Sign Language) are used in your home?

Have you ever had an investigation and/or a founded complaint of abuse, neglect or exploitation?
Yes  No

Have you ever been convicted of a felony?
Yes  No

Have you ever been convicted of a misdemeanor?
Yes  No

Respite providers offer short term, temporary care to an individual that currently receives services through LifeShare. Respite rates vary among individuals that we support.

Would you be interested in becoming a respite provider for LifeShare's current Shared Living Providers?
Yes  No

If yes, may we distribute your information to LifeShare home care providers in need of respite support?
Yes  No

Education

Employment Experience

Please provide your employment experiences.

No Prior Employment Experience

Have you ever been a Home Care/Foster Care Provider?
Yes  No

If so, with what agency were you affiliated with?

Dates and type(s) of certification/licensure

Household Members

Please list all people living at your home.

I live alone

References

Please list the names and phone numbers of four people we can contact. References must not be relatives.

Reference 1

Reference 1 - Phone Number

Reference 2

Reference 2 - Phone Number

Reference 3

Reference 3 - Phone Number

Reference 4

Reference 4 - Phone Number

Do you have any related experience in working with individuals in need of support? If so, please describe...

What interests you in becoming a Home Care/Foster Care Provider...

Additional Comments

I certify that all statements and information provided in this document are true, complete and correct to the best of my knowledge and are made in good faith. I understand that omissions, misleading, false or untrue information, or any attempt at fraud or deceit in any manner connected with this document may result in my not being considered as a provider with LifeShare Management Group, Inc. may constitute grounds for termination; and/or may constitute grounds for further actions pursuant to law. if request, I can and will supply documentation that will confirm that the entries made on this document are true, complete and correct.

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