New FMP

New Family Model Provider Questionnaire

Please all questions below.

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* 1. Please complete contact information.

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Why are you interested in providing supports for the elderly and/or persons with disabilities?

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* 3. What qualities do you have that you feel would make you a good caregiver?

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* 4. What do you consider to be the most challenging aspect of supporting a person?

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* 5. What type of daily activities would you plan for a person you supported?

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* 6. Are you able to assist with lifting and transferring for a person with mobility issues?

Yes

No

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* 7. Are you comfortable supporting a person who may need total assistance with hygiene, bathing, dressing, oral care, etc?

Yes

No

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* 8. How did you hear about us?

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* 9. 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.

Name

Email Address

Phone Number

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* 10. 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