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New FMP
New Family Model Provider Questionnaire
Please all questions below.
OK
*
1.
Please complete contact information.
(Required.)
Name
*
Address
*
Address 2
City/Town
*
State/Province
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
2.
Why are you interested in providing supports for the elderly and/or persons with disabilities?
(Required.)
*
3.
What qualities do you have that you feel would make you a good caregiver?
(Required.)
*
4.
What do you consider to be the most challenging aspect of supporting a person?
(Required.)
*
5.
What type of daily activities would you plan for a person you supported?
(Required.)
*
6.
Are you able to assist with lifting and transferring for a person with mobility issues?
(Required.)
Yes
No
*
7.
Are you comfortable supporting a person who may need total assistance with hygiene, bathing, dressing, oral care, etc?
(Required.)
Yes
No
*
8.
All Family Model Providers are required to have a back-up person on file. Please provide us with your back-up person's contact information.
(Required.)
Name
Email Address
Phone Number
9.
What time of day would be most convenient for you for someone from Group Effort to contact you for a short phone interview in the next 48 hrs?
9 am - 11 am
2 pm - 4 pm
5 pm or later
*
10.
How did you hear about us?
(Required.)
Radio
Indeed
Word of Mouth
Referred by Friend or relative
Social Media ( Instagram, Facebook)
Current Progress,
0 of 10 answered
