General Information

Do you live in a: *
Do you: *
Do you have renter’s or homeowner’s insurance? *
Do you have landlord approval to have a non-related individual move into your home? *
Do you have the minimum vehicle insurance required by the State of Rhode Island? *

Education

High School Diploma? *
College Degree? *
Graduate Degree? *

 

Interest

Personal Characteristics

Skills and Qualifications

Values

Challenges

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

References

Reference 1


Reference 2


Reference 3


Reference 4

Employment History

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









Members of Household









Do you have any frequent visitors/overnight guests? *

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.

List any medications you are currently taking
Do you drink alcoholic beverages? *
Have you or any member of your household ever been treated for, or had a drug or alcohol–related concern? *
Do you or other members of the household smoke? *
Do you have pets? *
Have you or any member of your household ever been engaged in counseling, psychiatric or psychological treatment? *
Have you had any motor vehicle violations (including accidents) in the last three (3) years? *
Have you or any member of your family/household ever been in foster care or out-of-home placements? *
Have you had any past experiences that may interfere with your ability to work with an individual who has been physically or sexually abused? *
Have you ever been debarred, excluded or otherwise ineligible for participation in any federal health care program such as Medicare or Medicaid? *
Have you or any member of your household ever had a charge of abuse or neglect substantiated against you/them? *
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? *
Do you have any friends or relatives who are Shared Living Providers? *
Have you ever been a Shared Living Provider or Foster Care provider before? *
Would you be willing to provide respite care, which is a temporary, shorter term living arrangement? *
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? *
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