Big Hearts Home Healthcare Homeshare

Big Hearts Home Healthcare Homeshare

Application
Date of submission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Applicant Information
Applicant's Name(s)

First NameMiddle NameLast Name
Other Name(s)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Employer
Position
Length of Employment
Languages Spoken
Secondary Applicant Information (If Applicable)
Applicant's Name

First NameMiddle NameLast Name
Other Name(s)
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Individual's Private Living Space
Will the individual have their own private bedroom?
Will the individual have their own private bathroom, or will it be shared?
Will the individual have their own living room/sitting area, or will the common living space be shared with the family?
Will the individual have a separate/private suite?
If there is a separate suite, does it have its own entrance?
Where in the home will the individual's bedroom/suite be located?
What areas of the home will be shared with the family?
Home & Environment
Do you own or rent your home?

Other
Are there stairs at the entrance of the home?
If yes, how many stairs are at the entrance?
Are there stairs inside the home that the individual would need to use?
Is there a wheelchair ramp?
Is the entrance wheelchair accessible?
Is the individual's proposed bedroom wheelchair accessible?
Is the bathroom wheelchair accessible?
Are the hallways and doorways wide enough for a wheelchair or walker?
Does the bathroom have any of the following accessibility features?

Other
If the bedroom is on another floor, is there an elevator or stair lift?
Driver's Licence, Vehicle and Parking
Do you have a valid driver's licence?
Is accessible parking available close to the entrance?
Do you have a reliable vehicle available for transporting the individual?
Describe your vehicles, including model, year, reliability, and availability
Overall, would you describe the home as fully wheelchair accessible, partially accessible, or not wheelchair accessible?
Children and Other Household Members
What are the ages of the children currently living in the home?
Are the children currently living in the home attending school, working, or regularly staying at home?

Other
Have the children been informed that the family is considering becoming a Home Share provider?
How do your children feel about having an individual receiving Home Share services living in the family home?
Are the children comfortable and supportive of the arrangement?
Has the spouse/partner been consulted?
Does the spouse/partner fully support the decision to become a Home Share provider?
Please discuss this commitment with your spouse/partner and children before committing to Home Share, because the placement will affect the entire household.
Criminal Record Check

Household members who are 19 years of age or older and are subject to the applicable Home Share screening requirements will be required to complete a Criminal Record Check.
Please provide the names and ages of all household members who are 19 years of age or older.
Program Interest

Open Your Home. Change a Life.
Interest in supporting with
Motivation & Background
What do you know about providing home sharing for children, youth, or adults with diverse abilities?
Why are you considering home sharing at this time?
Will others be impacted by this arrangement? If so, have they been consulted and are they supportive?
How long can you commit to home sharing?
Do you belong to any religious or cultural organizations? If yes, please describe.
How might home sharing impact your lifestyle, schedule, commitments, or priorities?
Please provide a brief work history and any relevant experiences.
Household Employment
Household Employment
Prior Support Experience
Please describe any prior home sharing, foster care, or respite support experience.
Do you currently support an individual with diverse abilities in your home? If yes, please describe the support provided.
Which agencies or organizations have you contacted, and have you been screened by any of them? Please provide details.
Household Composition
Household Members
Relationship to Primary Applicant
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
International Students
Are you a host family for international students?
Is a student currently in the home?
Age(s) of student(s)
Family & Lifestyle
Please describe your partner/spouse history and how long you have been together.
What strengths, interests, or hobbies do you and your partner/spouse have that would help you in a homeshare role?
What strengths, interests, or hobbies does your family have that would support a homeshare arrangement?
Please describe any community involvement, volunteer work, or local activities you participate in.
Please describe your smoking habits and your comfort level supporting someone who uses cigarettes, vaping, marijuana, other drugs, or alcohol.
Please describe any chronic health conditions that may affect your ability to provide support.
Please describe your regular holiday plans and how they may affect your ability to provide support.
Do you have any pets in the home? If yes, please describe
Describe your neighbourhood and proximity to services
How long have you lived there, and why have you settled there?
Is support responsibility entirely yours or shared? Please explain
Complex Needs & Support Comfort Level
Which complex needs or support areas are you comfortable supporting?
Comments
Training & Additional Information
What support or training would you need to become a home sharing provider?
Anything else we should know?
References – Primary Applicant
Primary Applicant Reference 1
Organization
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Name

First NameMiddle NameLast Name
Phone / Email
Reference consent Signature of Applicant
Reference consent Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
References – Secondary Applicant
Secondary Applicant References
Instruction: Provide three references for the secondary applicant.
Declaration & Signatures
Name of Primary Applicant

First NameMiddle NameLast Name
Signature of Primary Applicant
Date (Primary Applicant)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Secondary Applicant

First NameMiddle NameLast Name
Signature of Secondary Applicant
Date (Secondary Applicant)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Pictures

Cancelof
Should be Empty:

Big Hearts Home Healthcare Homeshare

Primary Applicant Information

Secondary Applicant Information (If Applicable)

Individual's Private Living Space

Home & Environment

Driver's Licence, Vehicle and Parking

Children and Other Household Members

Criminal Record Check

Program Interest

Motivation & Background

Household Employment

Prior Support Experience

Household Composition

International Students

Family & Lifestyle

Complex Needs & Support Comfort Level

Training & Additional Information

References – Primary Applicant

References – Secondary Applicant

Declaration & Signatures