Last Name (required)
First Name (required)
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? DenverMontbelloGreen Valley RanchLakewoodAuroraLittletonArvadaNorthglennWestminsterParker
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
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
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)