New FMP New Family Model Provider Questionnaire Please all questions below. OK Question Title * 1. Please complete contact information. Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK Question Title * 2. Do you have internet access and a computer? Yes No OK Question Title * 3. Do you have a vehicle and auto insurance? Yes No OK Question Title * 4. Do you have smoke detectors in the home, and one in each client's bedroom? Yes No OK Question Title * 5. Do you have a preference of gender? Male Female No Preference OK Question Title * 6. Do you have an age range preference? Yes No If YES, please state age range OK Question Title * 7. Is it important to you, for the individual to be able to communicate verbally? Yes No OK Question Title * 8. Are you comfortable supporting a person with incontinence/changing adult briefs? Yes No OK Question Title * 9. Are you able to assist with lifting and transferring for individuals with mobility issues? Yes No OK Question Title * 10. Are you comfortable supporting an individual with aggressive behaviors? Yes No OK Question Title * 11. Are you comfortable supporting an individual with mental health diagnoses? Yes No OK Question Title * 12. Are you comfortable supporting an individual who needs total assistance with hygiene, bathing, dressing, oral care, etc? Yes No OK Question Title * 13. Are you comfortable supporting an individual who has seizures? Yes No OK Question Title * 14. Are you able to transport or accompany a person to their medical appointments as needed? Yes No OK Question Title * 15. Are you willing to support an individual who smokes? Yes No OK Question Title * 16. Do you smoke? Yes No OK Question Title * 17. Do you mind if an individual wants to socially/occasionally consume alcohol? Yes No OK Question Title * 18. Do you have any pets in the home? Yes No If YES, please state the type and how many. OK Question Title * 19. Do you have children in the home? Yes No If YES, how many and what are the ages? OK Question Title * 20. Do you have anyone staying or living in the home 18 years of age or older? Yes No OK Question Title * 21. Do you have any weapons in the home? Yes No OK Question Title * 22. Why are you interested in providing supports for the elderly and/or persons with disabilities? OK Question Title * 23. What qualities do you have that you feel would make you a good caregiver? OK Question Title * 24. What are your hobbies and interests? OK Question Title * 25. What do you consider to be your weaknesses? OK Question Title * 26. What program are you interested in being a part of: CLS, ECF, or DIDD? CLS ECF DIDD All Above Unsure OK Question Title * 27. Have you ever completed Relias Training? Yes No If yes, for which agencies did you complete Relias with? OK Question Title * 28. How did you hear about us? OK Question Title * 29. 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 OK Question Title * 30. Please List a Professional Reference Name: Email Address: Company: Relationship: OK Question Title * 31. Please List Another Professional Reference Name: Email Address: Company: Relationship: OK Question Title * 32. Please List a Personal Reference Name: Email Address: Relationship: Years Known: OK Question Title * 33. Have you lived in Tennessee for the last 7 years? Yes No OK Question Title * 34. Are you Medication Administration certified? Yes No OK SUBMIT
