Host Home Provider Pre-Screening Form

Personal Information

Name

Primary Residence Address

City

State

Zip

Other Address (as applicable)

Housing Status

Are you able to sublease to others?

Phone

Questionnaire

Please answer each question as fully as you can. Your answers will help Ability United learn about your home, experience, and support needs, and preferences.

Home and Household

Who lives with you? Please include children, a spouse or partner, relatives, roommates, and anyone else who lives there. If you have children living with you, what are their ages?

Who visits your home on a regular basis? This may include grandchildren, other relatives, friends, neighbors, or service providers.

Do you have any pets? If yes, what kind of pets do you have, and how many?

Do you have any other employment? Is your home usually busy or quiet? How often are you active in the community? If you are approved as a host home provider, what changes or plans would you make?

Experience and Interest

Tell us about a difficult situation that you faced. How did you respond, and what did you learn from the experience?

Tell us about a positive experience that helped you grow and learn. What did you learn from it?

What experience do you have as a host home provider or in a similar caregiving role? How do you support a person who is showing challenging behavior? Please give an example.

Communication and Support

Have you identified a backup provider (sub)? If yes, please provide their name. Has this person helped you support members before, or do they have other experience working with members?

If you would like to keep this person as a backup provider (sub), they must also complete this form along with other required provider documentation.

Why are you interested in working for Ability United?

How did you hear about Ability United? If someone referred you, please provide that person’s name. If you are planning to become a backup provider (sub) provider for a host home provider, please list the host home provider’s name.

Do you have any concerns about becoming a host home provider? If yes, please explain.

What situations would lead you to ask Ability United for backup help? Please describe how you would contact the agency and follow up.

How would you communicate with a member’s team? Please give an example of a situation that would require you to contact the team.

Describe a time when you told a member’s team about a behavior concern. Explain what happened, how you shared the information, and what follow-up was needed.

Describe a positive event, or success that you shared with a member’s team. Explain what happened, who was involved, how you shared the information, and why the event was important.

Describe a time when you asked for guidance or requested a team meeting. Are there any support needs or situations you are not able or willing to manage? For example, are there types of aggressive behavior, or other safety concerns you cannot support? Please explain so you can consider the best possible match.

Home Layout and Accessibility

Describe the layout of your home and location of the member’s bedroom and bathroom. Include any stairs, step free entrances, and accessible bathroom features.

Are you comfortable helping members with personal care, attending appointments, and communicating with members who do not use spoken words? Please describe any tasks you are not comfortable doing.

How Would You Respond

How would you respond if a member used physical, sexual, or verbal aggression?

How would you respond if a member left a safe area without permission or supervision (elopement)?

How would you respond if a member needed or asked to go to the Emergency Room? How would you respond if a member was admitted to the hospital?

How would you respond if a member had contact with law enforcement?

How would you respond if you had concerns about a member’s use of alcohol or other substances?

Other Information

Is there anything else you would like us to know about you, your home, or the support you can provide?