1. Pre-placement assessment

Name:

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* 1. Name:

Co-applicant, if applicable

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* 2. Co-applicant, if applicable

Address:

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* 3. Address:

Email Address:

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* 4. Email Address:

Co-applicant email, if applicable

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* 5. Co-applicant email, if applicable

Are you aged 18 or over?

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* 6. Are you aged 18 or over?

Social Security Number

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* 7. Social Security Number

Co-applicant Social Security Number, if applicable

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* 8. Co-applicant Social Security Number, if applicable

Marital Status (choose one):

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* 9. Marital Status (choose one):

Telephone:

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* 10. Telephone:

Co-applicant Telephone, if applicable

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* 11. Co-applicant Telephone, if applicable

Occupation:

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* 12. Occupation:

Co-applicant Occupation:

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* 13. Co-applicant Occupation:

Would you be available during the day if someone placed in your home was unable to attend his/her day program/job?

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* 14. Would you be available during the day if someone placed in your home was unable to attend his/her day program/job?

Other Household Members

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* 15. Other Household Members

Descriptions of Home (stairs, number of bedrooms, composition of home, number of bathrooms; etc.):

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* 16. Descriptions of Home (stairs, number of bedrooms, composition of home, number of bathrooms; etc.):

I agree to a home study evaluation, which includes an inspection of my home, to determine my eligibility to provide shared living services.

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* 17. I agree to a home study evaluation, which includes an inspection of my home, to determine my eligibility to provide shared living services.

Do you have paying boarders?

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* 18. Do you have paying boarders?

Have you ever been a Shared Living provider, specialized care home or foster home for any public or private agency before?

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* 19. Have you ever been a Shared Living provider, specialized care home or foster home for any public or private agency before?

How long have you occupied your present home?

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* 20. How long have you occupied your present home?

Do you own or rent your present home?

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* 21. Do you own or rent your present home?

Do you have any pets?

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* 22. Do you have any pets?

Do you or any members in your household have any communicable diseases or disability?

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* 23. Do you or any members in your household have any communicable diseases or disability?

Do you or any member of your household have current or past problems with the use of alcohol or drugs? 

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* 24. Do you or any member of your household have current or past problems with the use of alcohol or drugs? 

Do you or any member of your household have current or past emotional problems?

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* 25. Do you or any member of your household have current or past emotional problems?

Do you have any physical limitations?

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* 26. Do you have any physical limitations?

Would you be able to accommodate someone in a wheelchair?

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* 27. Would you be able to accommodate someone in a wheelchair?

Are you presently under the care of a physician for treatment of a condition that would prevent you from caring for a cognitively or physically disabled adult?

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* 28. Are you presently under the care of a physician for treatment of a condition that would prevent you from caring for a cognitively or physically disabled adult?

Have you or any member of your household been convicted of a crime or have outstanding charges against you/them (Documentation may be requested)

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* 29. Have you or any member of your household been convicted of a crime or have outstanding charges against you/them (Documentation may be requested)

What experience have you had with the care of elderly or disabled persons?

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* 30. What experience have you had with the care of elderly or disabled persons?

Do you have any experience caring for disabled adults with medical conditions?

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* 31. Do you have any experience caring for disabled adults with medical conditions?

Why are you interested in this program?

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* 32. Why are you interested in this program?

Gender preference for the person you will serve as a shared living provider?

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* 33. Gender preference for the person you will serve as a shared living provider?

How do the other household members feel about having another person share their home?

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* 34. How do the other household members feel about having another person share their home?

Do you anticipate any problems which would interfere with your participation in the program for one year subsequent to the placement of a person in your home, i.e., moving, change in career or employment, change in household composition, etc.?

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* 35. Do you anticipate any problems which would interfere with your participation in the program for one year subsequent to the placement of a person in your home, i.e., moving, change in career or employment, change in household composition, etc.?

Do you have valid driver’s license?

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* 36. Do you have valid driver’s license?

Do you own a car?

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* 37. Do you own a car?

Is your vehicle insured?

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* 38. Is your vehicle insured?

Would you be willing to provide transportation for the individual as needed? 

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* 39. Would you be willing to provide transportation for the individual as needed? 

Hobbies, interests or usual leisure activities:

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* 40. Hobbies, interests or usual leisure activities:

Is smoking acceptable in the home?

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* 42. Is smoking acceptable in the home?

Previous Employment

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* 43. Previous Employment

Previous Employment of the Co-applicant, if applicable

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* 44. Previous Employment of the Co-applicant, if applicable

Current Certifications: (CPR, FIRSTAID, MANDT, other relevant trainings):

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* 45. Current Certifications: (CPR, FIRSTAID, MANDT, other relevant trainings):

Current Certifications of the Co-applicant, if applicable: (CPR, FIRSTAID, MANDT, other relevant trainings):

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* 46. Current Certifications of the Co-applicant, if applicable: (CPR, FIRSTAID, MANDT, other relevant trainings):

References:
Please provide names and occupations of at least three (3) persons not related to you and three (3) persons who have supervised your work as a reference to be contacted.

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* 47.

References:
Please provide names and occupations of at least three (3) persons not related to you and three (3) persons who have supervised your work as a reference to be contacted.

References for Your Co-applicant, if applicable
Please provide names, occupations of at least three (3) persons not related to your spouse and three (3) persons who have supervised his/her work as a reference to be contacted.

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* 48. References for Your Co-applicant, if applicable
Please provide names, occupations of at least three (3) persons not related to your spouse and three (3) persons who have supervised his/her work as a reference to be contacted.

I certify that all information on this Extended Family Teacher/Extended Family Home Provider pre-placement assessment about my home and myself is true and complete to the best of my knowledge. I understand that the Director or designee may check the information and references for the screening process. I release Community Living Opportunites and its representatives from liability for seeking such information and other persons for furnishing such information. I understand that this document does not constitute a contract. Any false or misleading information given here may result in cancellation of a contract. No statements during the interview or home study shall be construed as binding the agency to particular terms and conditions. All actual terms will be contained in the contract agreement.

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* 49. I certify that all information on this Extended Family Teacher/Extended Family Home Provider pre-placement assessment about my home and myself is true and complete to the best of my knowledge. I understand that the Director or designee may check the information and references for the screening process. I release Community Living Opportunites and its representatives from liability for seeking such information and other persons for furnishing such information. I understand that this document does not constitute a contract. Any false or misleading information given here may result in cancellation of a contract. No statements during the interview or home study shall be construed as binding the agency to particular terms and conditions. All actual terms will be contained in the contract agreement.

By submitting this pre-placement assessment I acknowledge that as an Extended Family Teacher/Extended Family Home Provider I will be in the role of an Independent Contractor. I will not list Community Living Opportunities (CLO) as an employer on official documents such as income verifications, loan applications, government forms, unemployment applications and others.

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