Exhibit E (PDF).pdf

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):

Homeshare Provider (one adult providing supervision of one non-relative client) Homeshare Dual Provider (two adults providing supervision of one non-relative client in same household) For payment purposes, please indicate to make check payable as follows:

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):

Homeshare Standard (one non-relative client in home) Homeshare Standard Respite (one temporary homeshare non-relative client in home with another homeshare client no longer than two weeks) Homeshare Enhanced Respite (South Carolina citizen in crisis needing short-term supervision and provider has no other non-relative client in home).

Race/Ethnicity: Sex: Male / Female (check one) Marital Status:

Religious Affiliation: Active / Inactive (check one)

Home (check 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? Yes / No, if yes, indicate what those restrictions are

How long have you lived at your present address (check 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): ________ Name Age Sex Relationship to you

(continue on back if necessary) 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+ (check one) Approximate annual household income: (check 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? (check 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? (check one) daily weekly monthly infrequently

How often do you have contact with relatives? (check 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

CHARGE LOCATION DATE RESULT

(Offense) (City/State) (Mo/Yr.)

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. ________________________________________________________________________________________ Name Telephone Relationship

Address

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.

Signature Date

Dual Provider Signature, if applicable Date