Pitre Housing Residential Care – Host Home Provider Application

Pitre Housing Residential Care – Host Home Provider Application

Thank you for your interest in becoming a Host Home provider with Pitre Housing Residential Care. Please complete the form below. Once your application is reviewed, we will contact you to discuss next steps and schedule a home visit.
Host Home Provider Minimum Requirements

To be considered as a Host Home provider with Pitre Housing Residential Care, applicants must be able to meet the following minimum requirements:
The Host Home Provider agrees not to provide Host Home or Companion Care services for individuals enrolled in HCS or TxHmL through any other provider agency, including group/boarding home comapnies, while contracted with Pitre Housing.
• Be 21 years of age or older
• Pass required criminal background checks
• Provide a safe and stable home environment
• Have a private bedroom available for the individual
• Allow home inspections as required by program guidelines
• Complete required training and orientation
• Maintain reliable transportation
• Comply with HCS / TxHmL program requirements
Yes, I meet these requirementsNo
Application Information
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Street Address*
City*
State*
Zipcode*
How long have you lived at the address*
Housing Information
Own (paying mortgage)Lease (paying rent)
YesNo
Type of residence*
How many bedrooms are in the home?*
How many bathrooms are in the home?*
YesNo
Household Members
Please list every person living in the home, including name, age, and relationship to you.*
Example: John Smith, 42, spouse
YesNo
YesNo
Caregiving Experience
YesNo
YesNo
Please describe any caregiving or disability support experience.*
Home Environment
YesNo
If yes, what type of pets?*
YesNo
YesNo
Placement Preferences
MaleFemaleEither
Please share anything else you would like us to know about your home environment or placement preferences.*
Required Document Uploads
High school diploma or GED*

Cancelof
Upload Driver License*

Cancelof
Upload Auto Insurance*

Cancelof
Upload photo of available bedroom*

Cancelof
Upload exterior photo of home*

Cancelof
Background Check Authorization

I authorize Pitre Housing Residential Care LLC to conduct the background checks and registry screenings required for Host Home providers, including criminal history and other compliance-related screenings.
Last 4 digits of Social Security Number*
Applicant Signature*
Date*

MonthDayYear
Date
Acknowledgement

I understand that submission of this application does not guarantee approval as a Host Home provider. Pitre Housing Residential Care will review the application, conduct required screenings, and complete a home assessment before approval.
Applicant Signature*
Date*

MonthDayYear
Date
Should be Empty:

Pitre Housing Residential Care – Host Home Provider Application

Host Home Provider Minimum Requirements

Application Information

Housing Information

Household Members

Caregiving Experience

Home Environment

Placement Preferences

Required Document Uploads

Background Check Authorization

Acknowledgement