Exhibit E

HOMESHARE PROGRAM APPLICATION

Disclaimer: Some of the information requested is for statistical purposes only and not determinative as to the acceptance or rejection of any individual application.

Name: ___________________________________________________________________________

Date of Birth: _____________________________________________________________________

Home Address: ____________________________________________________________________

County: ________________Home Telephone Number: ___________________Cell Phone_______________

Check below to indicate provider designation (only check one box):

Check below to indicate homeshare type designation requested (check as many boxes as you want to be considered for providing the homeshare service/designation type):

Sex: Male / Female (circle one) Marital Status: ___________ Race/Ethnicity:_________________

Religious Affiliation: _____________________________ Active / Inactive (circle one)

Home (circle one): Own Rent What is square footage of the home? ________________

Does your property deed, title, lease or local ordinance or other law related to the use of the property restrict or limit any of the Homeshare Program activities? ___________, if yes, indicate what those restrictions are __________________________________________________________________________________________________________________________________________________________________________________________

How long have you lived at your present address (circle one):

less than 1 year 2-5 years 5+ years

HOUSEHOLD COMPOSITION

Note* If you have a current client, do not list their name* Number of household members living in your home (including yourself): ________

Do you have any pets? Yes / No, If yes, what kind of pet?__________________________________ Is your pet(s) vaccinated for rabies and distemper combination? Yes / No If yes, date of vaccinations_________

Is your home near public transportation? Yes / No Explain Type: ______________________________________________________________________________________

Do you have a valid SC Driver’s License? Yes / No License #: __________________________ Do you have a car? Yes / No If you do not drive or have a car, how do you plan on transporting the individual for any of the described Homeshare Program Activities? __________________________________________________________________________________________________________________________________________________________________________________________

EMPLOYMENT

Are you currently employed outside the home? Yes / No Current Occupation: ______________________________________________________________________________________ Name & Address of Employer: ______________________________________________________________________________________

Business Telephone Number:_____________________________________________________________

Work Hours/Days: _____________________________________________________________________

If you are employed, will your work schedule allow you the flexibility to participate in Homeshare trainings/meetings, client programing (ex. PMA appt, etc.) or other identified activities within the homeshare program?

Yes / No

If no, explain how training/meetings and client appointments/programming will be maintained __________________________________________________________________________________________________________________________________________________________________________________________

Number of jobs in the last 5 years: 0 1-2 3-4 5+ (circle one) Approximate annual household income: (circle one) <$10,000 $10,000-$20,000 $20,000-$30,000 $30,000>

Have you ever been a foster parent? Yes / No

Are you employed in home? Yes / No If yes, specify_____________________________________ Work Hours/Days: _____________________________________________________________________

EDUCATION/TRAINING

What was the last grade you completed? (circle one) <6 7 8 9 10 11 12 some college completed college

Do you have any specialized training? Yes / No If yes, in what area? ______________________________________________________________________________________

Have you ever or do you currently do any volunteer work? Yes / No If yes, please explain: __________________________________________________________________________________________________________________________________________________________________________________________

How do you usually spend your free time? __________________________________________________________________________________________________________________________________________________________________________________________

What family activities do you enjoy? __________________________________________________________________________________________________________________________________________________________________________________________

What hobbies, interests, skills, or life experiences could you share with someone?__________________________________________________________________________________________________________________________________________________________________________________

How often do you have contact with friends and/or neighbors? (circle one) daily weekly monthly infrequently

How often do you have contact with relatives? (circle one) daily weekly monthly infrequently

What first interested you in this program? __________________________________________________________________________________________________________________________________________________________________________________________

What are your reasons for wanting to include a person from the community mental health center in your life/family? __________________________________________________________________________________________________________________________________________________________________________________________

Is there anything that you know of that would limit your ability to provide Homeshare support to a person from the community mental health center? _____________________________________________________________________________________________

Have you ever been convicted of any criminal offense other than minor traffic violations? Yes / No

Do you have any history of abusing, neglecting, or exploiting adults or minors? Yes / No Are you on the Child Abuse registry? Yes / No Are you on the sex offender registry? Yes / No If yes to the three questions above, please explain: __________________________________________________________________________________________________________________________________________________________________________________________

Additional information, comments, or questions?

References: (excluding family members)

1. ______________________________________________________________________________________ Name Telephone Relationship

Address

2. ______________________________________________________________________________________ Name Telephone Relationship Address

3. ________________________________________________________________________________________

By signing below, I agree to a home study and evaluation and a home standards check of my home, as well as a Criminal Records, National Sexual Offender Registry, Child Abuse and Neglect Central Registry, Motor Vehicle Licensure check. I also verify that no one in the household has a criminal, child abuse and neglect, and/or sex offender history and I will not allow anyone with any history of such to live in the house. I will inform Homeshare Staff immediately if anyone in my immediate or extended family is accused of or has a criminal, child abuse and neglect, and/or sexual offense history. I will pay a $26.00 fee at the appropriate time to conduct the Background Checks. I understand that personal reference checks from the three references I provided above may be conducted. I also understand that if I am selected I must provide a health certificate from my physician and a current two-step tuberculin screening. By signing this, I attest that all information contained in this application is true.