Professional Family Teaching Model (PFTM) Provider Pre-Placement Assessment

1. Pre-placement assessment

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* 1. Name:

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* 2. Co-applicant, if applicable

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* 3. Address:

Street

City

State

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* 4. Email Address:

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* 5. Co-applicant email, if applicable

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* 6. Are you aged 18 or over?

Yes

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* 7. Social Security Number

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

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* 9. Marital Status (choose one):

Married

Single

Separated

Divorced

Widowed

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* 10. Telephone:

Home:

Cell:

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* 11. Co-applicant Telephone, if applicable

Home:

Cell:

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* 12. Occupation:

Name of Company:

Address:

Telephone:

Current Job Title:

Hours Per Week:

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* 13. Co-applicant Occupation:

Name of Company:

Address:

Telephone:

Current Job Title:

Hours per Week:

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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?

Yes

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* 15. Other Household Members

1. Name:

Age:

Relationship to Care Provider:

2. Name:

Age:

Relationship to Care Provider:

3. Name:

Age:

Relationship to Care Provider:

4. Name:

Age:

Relationship to Care Provider:

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

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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.

Yes

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* 18. Do you have paying boarders?

None

Private

State

Other (please specify)

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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?

Yes

If, yes what agency and why did it end?

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

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

Own

Rent

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* 22. Do you have any pets?

Yes

Please list type and age of pets:

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

Yes

If yes, please provide details below:

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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?

Yes

If yes, please explain:

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

Yes

If yes, please explain:

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* 26. Do you have any physical limitations?

Yes

If yes, please explain:

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

Yes

If "No", please explain:

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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?

Yes

If yes, please explain:

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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)

Yes

If yes, please explain:

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

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

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* 32. Why are you interested in this program?

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

Male

Female

Either

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

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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.?

Yes

If yes, please explain:

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

Yes

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* 37. Do you own a car?

Yes

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* 38. Is your vehicle insured?

Yes

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

Yes

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* 40. Hobbies, interests or usual leisure activities:

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* 41. Number of smokers in the home:

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* 42. Is smoking acceptable in the home?

Yes

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* 43. Previous Employment

1. Name of Employer:

Type of Work:

Dates of Employment

2. Name of Employer:

Type of Work:

Dates of Employment

3. Name of Employer:

Type of Work:

Dates of Employment

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

1. Name of Employer

Type of Work

Dates of Employment

2. Name of Employer

Type of Work

Dates of Employment

3. Name of Employer

Type of Work

Dates of Employment

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

1. Type of Training:

Where:

When (Date):

2. Type of Training:

Where:

When (Date):

3. Type of Training:

Where:

When (Date):

4. Type of Training:

Where:

When (Date):

5. Type of Training:

Where:

When (Date):

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

1. Type of Training:

Where:

When:

2. Type of Training:

Where:

When:

3. Type of Training:

Where:

When:

4. Type of Training:

Where:

When:

5. Type of Training:

Where:

When:

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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.

1. Name

Occupation

Telephone

2. Name

Occupation

Telephone

3. Name

Occupation

Telephone

4. Name

Occupation

Telephone

5. Name

Occupation

Telephone

6. Name

Occupation

Telephone

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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.

1. Name

Occupation

Telephone

2. Name

Occupation

Telephone

3. Name

Occupation

Telephone

4. Name

Occupation

Telephone

5. Name

Occupation

Telephone

6. Name

Occupation

Telephone

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* 49. I certify that all information on this Professional Family Teaching Model 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 GoodLife Innovations 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.

Yes

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.