Homeshare Provider Application - First Step

Building Bridges only approves those with the skills, disposition, and physical accommodation to provide high quality home sharing support to adults with diverse abilities.

Home Share Coordinators complete a rigorous and comprehensive assessment prior to approving any home sharing provider. Approval does not necessarily guarantee that a contract will be established with the potential provider. Contracts will be established win the individual, her/his family, or support network members decide whether or not a potential candidate meets the individual’s needs and preferences for support.

Building Bridges contracted home sharing providers support only one individual at any given time. Exceptions can be considered if beneficial to the first individual in the home.

Application Date

Primary Applicant

Name

First Last

Other Names

Birth Date

Email*

Home Phone

Cell Phone

Work Phone

Current Employer

Position

Length of Employment

Languages Spoken

Are You A Building Bridges Employee?

Yes

Secondary Applicant (Secondary Caregiver)

Name

First Last

Other Names

Birth Date

Home Phone

Cell Phone

Work Phone

Current Employer

Position

Length of Employment

Languages Spoken

Are You A Building Bridges Employee?

Yes

Tell us why you want to become a Home Share Provider

What do you know about being a home share provider for an adult with diverse abilities?*

Why are you considering becoming a home share provider at this time?*

Will others be impacted by this decision (children, partner, others living in the home, etc.)? If so, have they been consulted and are they supportive of the choice?*

How long are you willing to commit to being a home share provider?*

Tell us about yourself and those who live within the home

List those who currently live within the home. Provide details about their relationship to the primary applicant and their birth dates.

Would you be comfortable supporting someone with complex needs? Please check the items you would be willing to support:

Consent*

May we contact you?

Email

This field is for validation purposes and should be left unchanged.

Homeshare Provider Application – First Step

Primary Applicant

Secondary Applicant (Secondary Caregiver)

Tell us why you want to become a Home Share Provider

Tell us about yourself and those who live within the home

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