QUESTIONS TO ASK AGENCIES/HOST HOME PROVIDERS



HOST HOME PROVIDER INFORMATION SHEETAgency Name: Real Care, Inc. Agency Contact Person: Sarah Crocket - sarah@ Agency Contact Phone: 303.284.5818Name: FORMTEXT ?????Date Completed: FORMTEXT ?????Email Address: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Phone #: FORMTEXT ?????Alternate Phone #: FORMTEXT ?????Please verify provider name including all pseudonyms and ‘also know as’ (AKA) names.Area of Town: FORMCHECKBOX Denver FORMCHECKBOX Montbello FORMCHECKBOX Green Valley Ranch FORMCHECKBOX Aurora FORMCHECKBOX Lakewood FORMCHECKBOX Littleton FORMCHECKBOX Arvada FORMCHECKBOX Northglenn FORMCHECKBOX Westminster FORMCHECKBOX Parker FORMCHECKBOX OtherMajor cross streets (i.e. Colfax and Havana or Iliff and I-225): FORMTEXT ????? PROVIDER EXPERIENCEYears as a Host Home Provider: FORMTEXT ????? or FORMCHECKBOX NewPlease give detailed description of your personal experience supporting individuals with intellectual / developmental disabilities: FORMTEXT ?????Please check the areas of individual support that you feel you are able to provide support to: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Single Individual FORMCHECKBOX Married Couple FORMCHECKBOX Religious Preference: FORMTEXT ?????Attend Church: FORMTEXT ????? (day of week, time, etc.) FORMCHECKBOX Behavioral Support FORMCHECKBOX Physical Aggression FORMCHECKBOX Verbal Aggression FORMCHECKBOX Property Destruction FORMCHECKBOX Sexualized Behavior FORMCHECKBOX Elopement FORMCHECKBOX Boundary Concerns FORMCHECKBOX Mental Health Support FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Medical FORMCHECKBOX Personal Care FORMCHECKBOX Feeding FORMCHECKBOX Bathing FORMCHECKBOX Toileting / Changing FORMCHECKBOX Transferring FORMCHECKBOX Frequent Medical appointments FORMCHECKBOX G-Tube FORMCHECKBOX Aspiration FORMCHECKBOX Frequent Positioning FORMCHECKBOX CAN FORMCHECKBOX RN Other languages: FORMTEXT ?????Please provide any information that you think would be helpful about your experience: FORMTEXT ?????TYPE OF HOMEPlease Describe Your Home: FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Townhouse FORMCHECKBOX Other: ______________# of Bedrooms Available: ___________# of Bathrooms: _____________Is your home wheelchair accessible? FORMCHECKBOX Yes FORMCHECKBOX NoDoes your home have stairs? FORMCHECKBOX Yes FORMCHECKBOX NoDo you own pets? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Dog(s) Description: FORMTEXT ????? FORMCHECKBOX Cat(s) Description: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX TransportationDescription of Vehicle: FORMTEXT ????? FORMCHECKBOX WC accessiblePlease list all individuals in the home:NameRelationship to HHPAge`Male / Female(double click on shaded boxes to enter information) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Are any of the above individuals person with disabilities? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please name: FORMTEXT ?????Is the individual with another CCB? If yes, please select one: FORMCHECKBOX RMHS FORMCHECKBOX DP FORMCHECKBOX NMCS FORMCHECKBOX DDRC FORMCHECKBOX Other: FORMTEXT ?????If you become a host home provider, do you plan to maintain outside employment? FORMCHECKBOX Yes FORMCHECKBOX NoPlease give a brief description of you, your family, your household, neighborhood, etc. that we can use to respond to referrals on your behalf. FORMTEXT ????? ................
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