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

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)

Please list the work schedules of anyone else in the home:

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:

If someone referred you to Pathways, please provide their first and last name:

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:

If your home is rented, what type of rental agreement do you have?

Month-to-month

One-year lease

Specify your own value:

If you are renting, is your landlord aware of and in agreement of you providing home share?

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:

Add Attachment

Home Share Provider Application - New Item