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Cedar Lake Residences
Family Home Provider Contractor Application
Will you be applying with a partner/spouse or alone? Note: If applying with partner, partner will also fill out application data.
*
Partner/spouse
Alone
How did you hear about us?
*
Please Select
Search Engine
Social Media
Friend
Current Employee
TV
Radio
Other
If a friend told you about us, who?
Please enter the full name.
If you heard about us from social media, which website?
Please enter the name of a social media site.
If other, how?
Applicant #1
Applicant #1
Full Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Non-Binary
Other
Prefer not to say
Date of Birth
*
/
Month
/
Day
Year
Date
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship Status
*
Please Select
Married
In a Relationship
Divorced
Widowed
Legally Separated
Single
If not married, current length of relationship with partner?
*
Enter number of years.
Profession
*
Please enter your work schedule below.
How many years have you lived in Kentucky?
*
States lived in last 5 years if not Kentucky:
*
States lived in last 5 years if not Kentucky:
Have you been convicted of a crime? If yes, please explain.
*
Applicant #2
Applicant #2
Full Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Non-Binary
Other
Prefer not to say
Date of Birth
*
/
Month
/
Day
Year
Date
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address (if different from Applicant #1)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Profession
*
If currently unemployed enter N/A
Please enter your work schedule below.
How many years have you lived in Kentucky?
*
States lived in last 5 years if not Kentucky:
*
States lived in last 5 years if not Kentucky:
Have you been convicted of a crime? If yes, please explain.
*
Licensing Questions
Licensing Questions
To be filled out with partner/spouse (if applicable)
How many people are you willing to support in your home? (Maximum of three)
*
Have you ever been previously been a Family Home Provider?
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Yes
No
If yes, what agency:
Agency
What state:
State
Have you ever been denied or terminated from being a Family Home Provider?
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Yes
No
If yes, explain:
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Have you ever had any APS or CPS investigations?
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Yes
No
If yes, explain:
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Getting to Know You
Getting to Know You
To be filled out with partner/spouse (if applicable)
Motivation for becoming a Family Home Provider:
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What is your biggest concern about being a Family Home Provider?
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How do you feel about interacting with all those that help support the individual living with you such as state officials, guardians, other team members and area providers?
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Will people be able to visit the individual living your home?
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What family supports do you currently have? Can any of these supports provide care temporarily if needed?
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What are your plans for care while you are at work?
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How do you feel about supporting an individual of a different race, religion, or culture? Is there any type of placement you would not be comfortable with?
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Are there any challenging behaviors you cannot support? Please explain.
What is your availability to complete required trainings
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Home Details
Home Details
Please answer these questions about your home where the individual you are supporting will be placed.
What type of home do you have?
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Single Family
Apartment/Condominium
Mobile Home
Number of Bedrooms
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Number of Bathrooms
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Is there a pool or body of water?
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Yes
No
If yes, is it fenced in?
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Yes
No
If no, would you be willing to fence it?
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Yes
No
Any plans to move in the next year?
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Yes
No
Do you have any pets? If so, how many and what kind?
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Do you own any weapons/firearms?
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Yes
No
Who is currently living or will be living in the home?
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Transportation
Transportation Plans
Please answer these questions about your vehicles.
Do you have license?
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Yes
No
Do you have a personal vehicle?
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Yes
No
Does you have auto insurance?
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Yes
No
Do you have any questions, comments, or concerns about becoming a Family Home Provider or Cedar Lake?
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Feel free to ask anything! There are no dumb questions here!
When is/are the best time(s) to contact you in regards to this questionnaire?
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During my work hours
After my work hours
Before my work hours
On the weekends
Take a moment to review your answers before submitting!
A member of our team will reach out to you should you qualify for an interview.
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