Host Home/ Companion Care Interest Form
Thank you for your interest in becoming a Host Home Provider with Pitre Housing. Please complete the information below, and a member of our team will contact you regarding next steps.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please enter your county of residence:
*
Have you, or anyone in the household, ever been convicted of a felony?
*
Yes
No
Are you willing to complete background checks and home inspections?
*
Yes
No
Have you been an Adult Foster Care / Host Home Provider before?
*
Yes
No
Are you willing to provide incontinent care?
*
Yes
No
Are you capable and willing to provide compassionate support for someone that needs assistance with activities of daily living?
*
Yes
No
Why are you interested in becoming a Host Home Provider?
*
Do you own or rent your home?
*
Own
Rent
Do you have an additional bedroom where someone could have their own private space?
*
Yes
No
Do you have a high school diploma or equivalent?
*
Yes
No
How would you like us to contact you?
*
Phone
Email
Text
Any
When is the best time to contact you?
*
Morning
Afternoon
Evening
Any
How did you hear about us?
*
Social media
Family/friend
Another Pitre Housing Host Home family
I understand that additional information and a full application will be required if selected to move forward.
*
I agree
Submit
Should be Empty: