New Family Model Provider Questionnaire 

Please all questions below.

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* 1. Please complete contact information.

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* 2. Do you have internet access and a computer?

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* 3. Do you have a vehicle and auto insurance?

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* 4. Do you have smoke detectors in the home, and one in each client's bedroom?

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* 5. Do you have a preference of gender?

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* 6. Do you have an age range preference?

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* 7. Is it important to you, for the individual to be able to communicate verbally?

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* 8. Are you comfortable supporting a person with incontinence/changing adult briefs?

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* 9. Are you able to assist with lifting and transferring for individuals with mobility issues?

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* 10. Are you comfortable supporting an individual with aggressive behaviors?

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* 11. Are you comfortable supporting an individual with mental health diagnoses?

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* 12. Are you comfortable supporting an individual who needs total assistance with hygiene, bathing, dressing, oral care, etc?

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* 13. Are you comfortable supporting an individual who has seizures?

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* 14. Are you able to transport or accompany a person to their medical appointments as needed?

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* 15. Are you willing to support an individual who smokes?

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* 16. Do you smoke?

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* 17. Do you mind if an individual wants to socially/occasionally consume alcohol?

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* 18. Do you have any pets in the home?

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* 19. Do you have children in the home?

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* 20. Do you have anyone staying or living in the home 18 years of age or older?

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* 21. Do you have any weapons in the home?

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

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

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* 24. What are your hobbies and interests?

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* 25. What do you consider to be your weaknesses?

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* 26. What program are you interested in being a part of: CLS, ECF, or DIDD?

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* 27. Have you ever completed Relias Training?

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* 28. How did you hear about us?

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* 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.

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* 30. Please List a Professional Reference

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* 31. Please List Another Professional Reference

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* 32. Please List a Personal Reference

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* 33. Have you lived in Tennessee for the last 7 years?

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* 34. Are you Medication Administration certified?

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