Home Share Provider Application

I understand that I must complete this application in one sitting (please review questions before applying) and progress cannot be saved.

Title

Applicant's name *

First Name & Last Name

Status

Home Share Coordinator assigned

Home Share Coordination Manager checked the Previous Home Share Provider Applicants list

Home Share Coordination Manager checked the Home Share - Do Not Consider list

Clear Criminal Record Check

Cleared other adult criminal record check(s)

Physician's Declaration Received

Driver's Abstract Received

Reference #1 Completed

Reference #2 Completed

Home Study Started

Health & Safety Checklist Completed

Home Study Completed

Notes:

Date Approved/Did Not Approve

Date of Birth *

MM/DD/YYYY

Main Phone Number *

Other Phone Number

Home Address *

Street Address, City, Province, Postal Code

Place of Birth *

Email Address *

Current Employer

Length of Current Employment

Occupation

What is your current work schedule (if applicable)?

(i.e. Monday to Friday 8am to 3pm)

Language(s) Spoken *

How did you hear about Pathways’ Home Share services? *

Castanet

Friend/family

Home share provider/staff

Facebook

Instagram

Specify your own value:

What interested you in supporting an adult with diverse abilities in your home? *

Who lives within the home?

List name, relationship to you, age of each person, their occupation (if applicable) and work schedule.

How did you meet your partner/spouse (if applicable)? How many years have you been together?

Are you affiliated with a specific religious and/or cultural organization? If yes, describe your level of participation. *

Describe you and your family’s strengths, interests, and hobbies. How would these contribute to you being a good home share provider? *

How are you and your family involved in your community (i.e. volunteer work, sports, recreational activities, clubs/associations, church)? What is your role in these activities, and how frequently do you participate? *

Briefly outline your work history along with any relevant and specific work experiences supporting individuals with diverse abilities. *

If your application is approved, what support and/or training do you feel you will need to be successful as a home share provider?

Describe the model, year, reliability, and availability of your vehicle(s). *

Which of the following apply? Your home is: *

Owned

Leased

Rented

Specify your own value:

What type of home do you live in? *

Single family house

Apartment

Townhome

Mobile home

Specify your own value:

Briefly describe the layout of your home. *

Include number of bedrooms and bathrooms, yard space.

Where in the home would the individual’s bedroom be? Would they share a bathroom and kitchen with other members of the household? *

Is the home accessible to someone who uses a wheelchair or walker? *

Yes

No

Specify your own value:

Please describe any features of the home that may support or limit accessibility (i.e. stairs, ramps, elevator, walk-in shower or tub, etc.). *

Are there pets in the home? *

Yes

No

If yes, specify the type, breed, age, etc.

Would the individual you support be able to have a pet? *

Yes

No

Specify your own value:

Have you provided foster care, home share, or respite services in the past? *

Yes

No

Specify your own value:

If yes, when and through which agency?

Have you been terminated by another service provider in the past? *

Yes

No

If yes, please describe the reason why you were terminated.

Are you currently supporting an individual with diverse abilities in your home?

Yes

No

Specify your own value:

If yes, provide details and for how long.

Do you or any other members living in your home smoke or vape? *

Yes

No

Specify your own value:

How would you feel about supporting someone who smokes cigarettes or marijuana? *

Is there a particular age group you would prefer to provide care for? *

Young adults 19- 35 years of age.

Adults aged 35- 65.

Older adults 65 plus.

Specify your own value:

Is there a specific gender that you would prefer to provide care for? *

Male

Female

Non-Binary

Open to everyone

Specify your own value:

Would you be comfortable supporting an individual who is a member of the LGBTQIA+ community? *

Yes

No

If no, please explain why.

How many individuals would you be willing to provide support for (maximum 2)? *

One

Two

What best describes the level of supervision you are able to provide? *

Fully available to supervise.

Only available evenings and weekends.

Available on a rotating basis (schedule varies).

Work part-time so available sometimes.

Work as a casual so able to adapt schedule as needed.

Specify your own value:

How often will you be available to provide transportation? *

Daily

A few times per week

Occasionally (available around work schedule)

Minimally

Not at all

How close to your home is the nearest bus route? *

Less than a 5-minute walk

5 - 20 minute walk

More than a 20-minute walk

There is no available public transportation within walking distance

Check off the skills/abilities that apply to you.

How prepared are you to provide personal care (i.e. assisting in the washroom, bathing, etc.)? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to teach an individual to learn self-care and other life skills? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to administer medication? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to support someone who experiences seizures and/or is epileptic? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to assist with special dietary needs (i.e. Celiac disease, Diabetes, etc.)? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to support an individual who experiences suicidal ideation, and providing intervention when needed? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to support an individual who is alcohol dependent? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to support an individual that is substance dependent? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to help educate an individual on safe sexual practices? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to support an individual who engages in violent or destructive behaviors? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to participate in individual service plan meetings with Pathways, and assist the individual to reach their goals? *

Fully prepared

Could frequently

Could occasionally

Not prepared

How prepared are you to follow an individual's behavior support or safety plan (if applicable)? *

Fully prepared

Could occasionally

Could frequently

Not prepared

If you are approved, when would an individual be able to move in? *

Is there anything else you would like us to know?

By checking this box, I declare that the information contained in this application is true to the best of my knowledge, and believe that I have not omitted any pertinent information.

Attachments:

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Home Share Provider Application - New Item