• Hands In Unity LLC

     

  • Family Model Provider (FMP) Application Form

  • Please complete all sections of this application. This information is required for screening, background verification, and compliance with TennCare, HCBS, and DDA provider standards.

  • 1. Applicant Information

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • 2. Household Members (All Adults 18+ Living in the Home)

  • List every adult currently living in the home. Background checks may be required for all adults.
  • *

  • 3. Employment History (Last 5 Years)

  • *

  • 4. Caregiving Experience

  • 5. Certifications / Training

  • Certifications / Training*

  • 6. References

  • List three professional references and three personal references.
  • Professional References*
  • Personal References*

  • 7. Background Screening Questions

  • Have you ever been convicted of a crime that would affect your ability to work with vulnerable adults?*
  • Have you ever been listed on an abuse or neglect registry?*
  • Have you ever been terminated from a caregiving or healthcare position?*

  • 8. Home Environment (Family Model Providers)

  • Will the person supported have a private bedroom?*
  • Do you have working smoke detectors?*
  • Do you have reliable transportation?*

  • 9. Applicant Agreement

  • I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification or termination from the application process.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date Reviewed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: