Pre-Screening Application Test

Full Name(required)

Cell Phone(required)

Full Home Address(required)

Date(required)

Email address(required)

County of Residence(required)

(Please note, this application is for Louisville, Kentucky and surrounding areas. This application does NOT cover Indiana or places outside of Jefferson, Shelby, Oldham and Bullitt counties.)

Family Home Providers (FHP) Provide daily care in their home for someone that becomes a part of their family. Co-Family Home Providers (Co-FHP) provide the same level of care but for short stays only.

Are you Interested in being considered for FHP? (required)

Yes

No

Are you Interested in being considered for both? (required)

Yes

No

Is it a Single level or Multi level home?(required)

Single Level

Multi-Level

Do you own your home? (required)

Yes

No

Are you Interested in being considered for Co-FHP?(required)

Yes

No

Is your home accessible? (required)

Yes

No

Are there common areas/bedrooms/bathroom on first floor? (required)

Yes

No

(Please note, it is important that you give detailed information in each area.)

1. How did you hear about Tri-Generations?(required)

Were you referred by someone? If so, Who?

2. Tell us what attracts you to sharing your home and life with an individual with disabilities? (required)

3. In today’s world we are utilizing technology a great deal for monitoring, data collection and communications. How do you rate your abilities to use technology like using a desktop computer, laptop, tablet or smart phone? (required)

4. Are you currently or previously working in this role of Family Home Provider with another SCL agency? If yes, please list the agency as this will facilitate accessing your College for Direct Support training records. (required)

If you are currently providing residential services, tell us why are you interested in working with us? (required)

If you have provided SCL residential services in the past and are no longer doing so, please tell us what happened.(required)

5. Are you applying with other agencies?(required)

6. Tell us about your work and life experiences with people with disabilities, specifically individuals with intellectual or developmental disabilities.(required)

7. Tell us about your work and life experiences related to caregiving. (required)

8. How flexible is your schedule? Are you available to take an individual to doctor’s appointments, or stay home with her/him when sick, attend planning meetings and such?(required)

9. What is your main source of transportation? Is it reliable?(required)

10. Do you have any limitations that might prohibit you from performing the essential functions of the service? Such as:(required)

Providing personal care:

Lifting:

Behavior Supports:

Driving/transportation:

Anything Else?

11. Many of the people with disabilities we work with have had a lot of people come in and out of their lives. They have been wounded by much of this loss. For this reason, we ask providers to make a commitment to this work. This is a very serious position, caring for another person, and we need to develop a trusting relationship with all people involved in that person’s life. How do you feel about that?(required)

12. As you can imagine, this is a very important position, with a lot of responsibility working with people who have disabilities. There are a number of required pre-employment screenings. These pre-employment screenings are required for you, as well as anyone over the age of 18 living in your home. Would you anticipate any problem with a criminal records check, the abuse registry, or pre-employment and periodic drug screenings? If yes, please explain.(required)

13. We require a lot of training before and after you start providing a service. Some of the training is scheduled in the Tri-Generations office and some training can be completed online. Can you be available to complete this requirement within the designated timeframe?(required)

The above information is true and complete to the best of my knowledge and belief. I am aware that should an investigation disclose falsification or misrepresentation, my application will be rejected.

Yes

No

Tri-Generations-Louisville
FHP/Co-FHP Pre-Screening Application

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Pre-Screening Application Test

Tri-Generations-Louisville FHP/Co-FHP Pre-Screening Application

Contact Us

Search

Tri-Generations-Louisville
FHP/Co-FHP Pre-Screening Application