Residential Form

Name of Caregiver *

Gender
FemaleMale

Are you interested in?
Foster Home (Children)Host Home (Adults)Both

The makeup of your Home
Single Parent HouseholdTwo-Parent Household

Do you have other permanent supports in home?
YesNo

Children
YesNo

Ages

Animals
YesNo

Employee of CentrePoint Support Living?
YesNo

Length

If not employee of CentrePoint Support Living, have you had other experiences, please describe where, when and length.

Behaviors you have dealt with
AggressionSelf Abusive BehaviorCriminal BehaviorMental Health ( Schizophrenia, Bi-polar, Mood Disorder, Psychosis)Mental Retardation

Description of specific dealings related to the above behaviors

Some clients like to smoke and some like to drink. Please mark your preference, if any
SmokingDrinkingNeither

Some clients have pets will they be allowed in your home?
YesNo

Do you as a Host Home Provider have Pet(s) in your home?
YesNo

Date of Application *

Last Name *

First Name *

Middle Name

Street Address

City

State

Zip Code

Phone Number *

Alternative Phone Number

Email Address

Social Security Number *

Birth Date

Birth Place

Gender
FemaleMale

Occupation

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Street Address

City

State

Zip Code

Phone Number

Alternative Phone Number

Email Address

Social Security Number

Birth Date

Birth Place

Gender
FemaleMale

Occupation

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Birth Date

Birth Place

Gender
FemaleMale

Relationship to Applicant 1

Relationship to Applicant 2

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Birth Date

Birth Place

Gender
FemaleMale

Relationship to Applicant 1

Relationship to Applicant 2

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Birth Date

Birth Place

Gender
FemaleMale

Relationship to Applicant 1

Relationship to Applicant 2

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Social Security Number

Birth Date

Birth Place

Gender
FemaleMale

Occupation

Education

Religion

Special Interests

Last Name

First Name

Middle Name

Social Security Number

Birth Date

Birth Place

Gender
FemaleMale

Occupation

Education

Religion

Special Interests

Name

Date of Birth

Whereabouts

Name

Date of Birth

Whereabouts

Name

Date of Birth

Whereabouts

Name

Date of Birth

Whereabouts

Are you or a member of your family currently being treated for a medical or psychological illness?
YesNo

Name

Relationship

Best Phone Number

Email Address

Name

Relationship

Best Phone Number

Email Address

Have you ever applied to become a home care provider?
YesNo

Have you ever been certified to provide care in our home to others?
YesNo

Have you ever been denied a certificate?
YesNo

If Yes for any of the above situations: What Agency?

Have you ever cared for another person in your home?
YesNo

Gender
FemaleMaleEither

Behaviors you have dealt with
AggressionSelf Abusive BehaviorCriminal BehaviorMental HealthSchizophreniaBi-polarMood DisorderPsychosisMental RetardationElopement (runner)Sexual Behavior Misconduct

Current Marital Status
SingleMarriedDivorced

Date of Marriage or Length of Relationship

State where married

How did the relationship end?
DivorceDeathOther

Verification of Marriage or Divorce?
YesNo

Date of Marriage or Length of Relationship

State where married

How did the relationship end?
DivorceDeathOther

Verification of Marriage or Divorce?
YesNo

Date of Marriage or Length of Relationship

State where married

How did the relationship end?
DivorceDeathOther

Verification of Marriage or Divorce?
YesNo

Have you or anyone living with you, ever been arrested, convicted of, received a deferred prosecution, or deferred judgment for any of the following?
YesNo

Please check all that apply
FelonyChild AbuseCrime of ViolenceDomestic ViolenceSexual offenseDrug OffenseConvictionDeferred ProsecutionDeferred Judgment

If any above is checked, please describe in full: Include name at the time, date of the arrest or conviction, type of conviction, what city and state did this occur

Do you live in a
HouseApartmentTownhouse/Condominium

Please give the layout of the house
2 Story HomeBasement with BedroomBasement Apartment OptionRanchSplit Level

Do You
OwnRent

Are you or anyone in the home a current or past employment of CentrePoint Support Living?
YesNo

Name of Employer

Title of Position

Address of employer

Gross Monthly Income

Dates Employed

Name of Employer

Title of Position

Address of employer

Gross Monthly Income

Dates Employed

Name of Employer

Title of Position

Address of employer

Gross Monthly Income

Dates Employed

Item

Amount

Item

Amount

Item

Amount

Item

Amount

Item

Amount

Item

Amount

Item

Amount

Item

Amount

Health
YesNo

Name of Provider

Life
YesNo

Name of Provider

Home/Rental
YesNo

Name of Provider

Automobile
YesNo

Disability

Name

Phone Number

Mailing Address

Name

Phone Number

Mailing Address

Name

Phone Number

Mailing Address

Name

Phone Number

Mailing Address

303-591-2185

terry@centrepointsupportliving.com

About Our History:

Find Us:

CentrePoint Support Living