General Information

Date *

Applicant *

Date of Birth *

Co-Applicant

Co-Applicant Date of Birth

Address: *

City *

State *

Postal Code *

Home Phone *

Cell Phone *

Work Phone *

Email Address *

Do you: *

Rent

Own

Do you have renter’s or homeowner’s insurance? *

Yes

Do you have landlord approval to have a non-related individual move into your home? *

Yes

Haven't Asked Yet

How long have you lived at your current address? *

Total number of rooms in your home *

Number of bedrooms *

Do you have the minimum vehicle insurance required by the State of Rhode Island? *

Yes

If you do not drive, how would you ensure transportation for an individual? Please be specific as you will be responsible for most transportation. *

Education

High School Diploma? *

Yes

College Degree? *

Yes

College Degree/Type? *

School *

Graduate Degree? *

Yes

Graduate Degree/Type? *

School *

Certifications

Please attach a copy of an updated resume. Please include any information you feel is relevant concerning your education (I.E., workshops, in-service trainings, etc.)

Interest

Why do you want to be a Shared Living Provider? *

Personal Characteristics

What personal qualities do you possess that you believe will assist you to be effective as a Shared Living Provider? *

Skills and Qualifications

Please describe any skills, qualifications and training acquired from employment and/or other experiences that may assist you to be effective as a Shared Living Provider. *

Is there any additional information about you and/or your family that you would like us to consider? *

Values

Please list the four most important values held by you and your family. *

Challenges

What do you foresee to be the greatest challenges involved in welcoming an adult with disabilities into your household? Please be specific. *

Have you considered the possibility of lifestyle changes your family may need to make in order to welcome an adult with disabilities into your household? *

Yes

Are you and your family willing to make lifestyle changes if necessary to accommodate a particular individual? *

Yes

Not Sure

References

Reference 1

Name *

Address *

Phone *

Relationship *

Reference 2

Name *

Address *

Phone *

Relationship *

Reference 3

Name *

Address *

Phone *

Relationship *

Reference 4

Name *

Address *

Phone *

Relationship *

Employment History

Starting with present or most recent employer, please account for all employment.

Company Name *

Address *

City *

State *

Zip Code *

Telephone *

Supervisor *

Job Title/Description of Duties *

Reason for Leaving *

Employed From (MM/YYYY) *

To (MM/YYYY) *

Company Name *

Address *

City *

State *

Zip Code *

Telephone *

Supervisor *

Job Title/Description of Duties *

Reason for Leaving *

Employed From (MM/YYYY) *

To (MM/YYYY) *

Company Name *

Address *

City *

State *

Zip Code *

Telephone *

Supervisor *

Job Title/Description of Duties *

Reason for Leaving *

Employed From (MM/YYYY) *

To (MM/YYYY) *

Company Name

Address

City

State

Zip Code

Telephone

Supervisor

Job Title/Description of Duties

Reason for Leaving

Employed From (MM/YYYY)

To (MM/YYYY)

Company Name

Address

City

State

Zip Code

Telephone

Supervisor

Job Title/Description of Duties

Reason for Leaving

Employed From (MM/YYYY)

To (MM/YYYY)

Members of Household

Name *

Relationship *

Date of Birth *

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

Do you have any frequent visitors/overnight guests? *

yes

Please describe your experience with individuals with disabilities. This may include volunteer experiences and providing respite care. *

Applicant History

Please answer the following questions in detail. All of this information will be discussed on an individual basis during the personal interview.

Please provide the name and contact information for your primary care physician. Your physician will be asked to complete a simple form providing his or her opinion on your ability to become a Shared Living Provider based on your physical health.

Physician's Name *

Address *

Phone *

Describe any major medical problems you have had treatment for in the past 10 years. *

List any medications you are currently taking

Do you drink alcoholic beverages? *

Yes

How many drinks do you usually have in a week? *

Have you or any member of your household ever been treated for, or had a drug or alcohol–related concern? *

Yes

Please explain *

Do you or other members of the household smoke? *

Yes

Do you have pets? *

Yes

Please list the type of animal, their name and their temperament *

Have you or any member of your household ever been engaged in counseling, psychiatric or psychological treatment? *

Yes

Please explain *

Have you had any motor vehicle violations (including accidents) in the last three (3) years? *

Yes

Please explain *

Have you or any member of your family/household ever been in foster care or out-of-home placements? *

Yes

Please explain *

Have you had any past experiences that may interfere with your ability to work with an individual who has been physically or sexually abused? *

Yes

Please explain *

Have you ever been debarred, excluded or otherwise ineligible for participation in any federal health care program such as Medicare or Medicaid? *

Yes

Please explain *

Have you or any member of your household ever had a charge of abuse or neglect substantiated against you/them? *

Yes

Please explain *

Have you or any member of your household been convicted of a misdemeanor or felony in any jurisdiction within or outside the state of Rhode Island? *

Yes

Please explain *

Do you have any friends or relatives who are Shared Living Providers? *

Yes

Please explain *

Have you ever been a Shared Living Provider or Foster Care provider before? *

Yes

Please explain *

Please describe your interests and hobbies. *

Would you be willing to provide respite care, which is a temporary, shorter term living arrangement? *

Yes

Do you understand that as a contracted Home Provider, you will not be an employee of AccessPoint, and will not be entitled to healthcare or other benefits afforded to agency employees? *

Yes

You may have a job outside the home, but you will have specific obligations as a home provider, as stated in a contract between you and AccessPoint RI. You will have the opportunity to review the contract prior to making any decision.

Thank you for taking the time to fill out this application completely. Please read the important statement below, then sign and date this form.

I authorize full review and verification of my experience/education as well as verification of any and all information provided by me or any member of my household for purposes of advancing to the next step in the process of becoming a Shared Living Home Provider with AccessPoint RI. I release from liability any person giving or receiving such information. Any material misrepresentation or deliberate omission of a fact on this request for consideration may be justification for refusal of, or if contracted with, termination of said contract. I understand that AccessPoint RI will conduct the following clearance checks on all members of my household who are over the age of 18:

Criminal (BCI)
of Motor Vehicle
Office of the Inspector General (OIG)
DCYF Clearance

I have read and understand the above.

Signature: *

Date *

Notes