HOST HOME APPLICATION

 
Please complete the form below to be considered by Shared Touch, Inc. to be a host home. We will review your application and get back to you at our earliest convenience. Thank you.

Last Name (required)

First Name (required)

Birth Date

Address

Address 2

City

State

Zip/Postal Code

County

Telephone (required)

CellHomeWork/Office

Alternative Telephone

CellHomeWork/Office

Your Email (required)

Have you ever been convicted of a crime? (required)
YesNo

Have you ever applied at Shared Touch, Inc. before? (required)
YesNo

Which best describes your current family? (required)
SingleMarried CoupleFamily with Children

How did you hear about us?

List below the person(s) living in your home. List each person on a separate line and include their name, age and relationship to the potential provider.

Will any other person(s) be staying in your home?
YesNo

If yes, who?

Do you rent or own your home?
OwnRent

How many years at your current address?

How many bathrooms?

How many bedrooms?

What part of town are you in?

What are the major cross streets?

What type of home do you live in?
ApartmentHouseCondoTownhomeMobile Home

Is it wheel chair accessible?
YesNo

Where is the room that is available for a customer?
Main LevelUpstairsBasementMother-In-Law (detached)

Please give a full description of your residence (ranch style, tri-level, separate living quarters for the consumer, wheel chair accessible, number of bedrooms and bathrooms). Please also give a description of the area your residence is located in (stores, community resources, bus lines, etc.)

Would you be willing to make adaptations for handicap devices?
YesNo

Do you drive a vehicle?
YesNo

Make/Model:

Insurance Carrier:

What is the type of insurance coverage
Full CoverageLiability Coverage

How many passengers does this vehicle safely transport?

Have you had any vehicle accidents/tickets within the last 5 years?
YesNo

If yes, explain:

Do you have pets?
YesNo

If yes, explain...what kind and how many?

Would the customer be allowed to have a pet?
YesNo

If yes, explain...what kind and how many?

Do you currently have a customer in your home?
YesNo

If yes, what agency are you currently with and how long have the been in your home?

What prompted you to pursue becoming a residential provider for a person with a disability? How many years have you been a provider or are you new?

Define your role as a Host Home Provider. How long do you foresee yourself as providing a Host Home?

What, if any other languages do you speak, read and/or write fluently?

What experiences have you had working with behaviorally challenged individuals?

What experiences have you had working with dually diagnosed individuals (example: mentally underdeveloped and mental illness)?

What experiences have you had working with sexually inappropriate behaviors?

Describe the disabilities and/or challenges you believe you are MOST “comfortable” working with.

Describe the disabilities and/or challenges you believe you are LEAST “comfortable” working with.

Does any member of your household have any chronic health problems/communicable diseases/other ongoing issues which way affect your responsibilities as a Provider? If yes, please explain:

Are you currently in good physical and mental health? If no, please explain:

Have you ever been involved in a drug treatment program? If yes, please explain:

Do you have any other remarks you’d like for us to know that may be helpful in considering you as a host home provider and making a good match?

By typing your name below (required) you acknowledge that you have completed this application to the best of your ability and that the information you have provided on this application is correct and truthful.(required)