Professional Family Teaching Model Provider Application
To be completed by each potential provider
Email address *
Name *
Telephone Number *
Birthdate *
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Social Security Number *
Marital Status *
Home Address *
How long have you lived at this address? *
Do you rent or own your home? *
Description of Home (Stairs, number of bedrooms, number of bathrooms, fenced yard, etc.) *
I agree to a home study evaluation, which includes an inspection of my home, to determine my eligibilty to provide PFTM services *
Current occupaton Information (Include company name, address, telephone, current job title, hours worked per week) *
Would you be available during the day if someone placed in your home was unable to attend his/her day program/job? *
Other Househhold Members (For each person living in your home please include full name, age, and relationship to you) *
Do you have paying boarders? *
Have you ever been a Shared Living provider, specialized care home or foster care for any public or private agency before? *
If you have been a Shared Living provider, specialized care home or foster care provider for any public or private agency before, what is the name of the agency and when did it end? *
Do you have any pets? *
If you have pets, list each type of pet and ages of each pet
Do you or any member of your household have any communicable diseases or disability? *
If you or any member of your household has any communicable diseases or disability, please provide details below
Do you or any member of your household have current or past problems with the use of alcohol or drugs? *
If you or any member of your household have current or past problems with the use of alcohol or drugs, please explain below
Do you or any member of your household have current or past emotional problems? *
If you or any member of your household have current or past emotional problems, please explain below
Do you have any physical limitations? *
If you have any physical limitations, please explain below
Would you be able to accomodate someone in a wheelchair? *
If you would be able to accomodate someone in a wheelchair, please explain below
Are you presently under the care of physician for treatment of a condition that would prevent you from caring for a cognitively or physically disabled adult? *
If you are presently under the care of a physician for treatment of a condition that would prevent you from caring for a cognitively or physicially disabled adult, please explain below
Have you or any member of your household been convicted of a crime or have outstanding charges against you/them? (Documentation may be requested) *
If you or any member of your household has been convicted of a crime or have outstanding charges against you/them, please explain below
Do you have experience caring for elderly or disabled persons? *
Do you have any experience caring for disabled adults with medical conditions? *
What interests you in the PFTM program? *
Do you have a gender preference for the person you will serve as a professional family teacher? *
How do the other household members feel about having another person share their home? *
Describe any anticipated problems which could interfere with your participation in the program for one year subsequent to the placment of a person in your home (i.e., moving, change in career, household compostion) *
Do you have a valid drivers license? *
Do you own a car? *
Is your vehicle insured? *
Would you be willing to provide transportation for the individual as needed? *
What are your hobbies, interests or usual leisure activities? *
Number of smokers in your home *
Is smoking acceptable in your home?
Your last three employments (Include name of company, type of work, and dates of employment) *
Spouse/Partner's last three employments, if applicable (Include name of company, type of work, and dates of employment)
Current certifications (e.g., CPR, First Aid, other relevant trainings). Include type of training, where completed, and when completed *
Spouse/Partner's current certifications (e.g., CPR, First Aid, other relevant trainings). Include type of training, where completed, and when completed *
Please provide one (1) person who has supervised your work as a reference to be contacted (Include name, occupation, address, and phone number) *
Please provide contact information for three (3) personal references to be contacted (Include name, occupation, address, and phone number) *
I certify that all information on this Professional Family Teacher application about my home and myself is true and complete to the best of my knowledge. I understand that the Director or designee may check the information and references for the screening process. I release GoodLife Innovations and its representatives from liability for seeking such information and other persons for furnishing such information. I understand that this document does not constitute a contract. Any false or misleading information given here may result in cancellation of a contract. No statements during the interview or home study shall be construed as binding the agency to particular terms and conditions. All actual terms will be contained in the contract agreement. *
By submitting this application I acknowledge that as a Professional Family Teacher I will be in the role of an Independent Contractor. I will not list GoodLife Innovations as an employer on official documents such as income verifications, loan applications, government forms, unemployment applications and others. *
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