Shared Living Provider Questionnaire

Contractor Information and Qualification Questions:

Shared Living Provider Name(*)

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Address (Street, City, State, Zip)(*)

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Years at current address(*)

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Prior Address(*)

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Phone #(*)

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Cell Phone #(*)

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Email Address(*)

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Names of other adults (over 18) living in the home(*)

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How did you learn about being a Home Provider or Respite Provider(*)

How did you learn about being a Home Provider or Respite Provider

Newspaper/Advertisement (Please tell us where below)

Agency

Contact Word of Mouth/Relative or Neighbor

Other Source (Please explain below)

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Where or Other Source

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1. Do you understand that you and the other adults living in your home will be subject to multiple types of background checks before completing this process?(*)

1. Do you understand that you and the other adults living in your home will be subject to multiple types of background checks before completing this process?

Yes

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2. Are you a legal resident of Maine or the United States?(*)

2. Are you a legal resident of Maine or the United States?

Yes

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3. Do you have a valid Maine Driver’s License?(*)

3. Do you have a valid Maine Driver’s License?

Yes

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4. Do you have an automobile and insurance for the automobile with a minimum coverage of $100,000k/$300,000k?(*)

4. Do you have an automobile and insurance for the automobile with a minimum coverage of $100,000k/$300,000k?

Yes

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5. Have you ever been substantiated for abuse/neglect/exploitation of children or other individuals?(*)

5. Have you ever been substantiated for abuse/neglect/exploitation of children or other individuals?

Yes

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6. Have you ever had a license or certification, to operate a residential care facility denied or placed on conditional status?(*)

6. Have you ever had a license or certification, to operate a residential care facility denied or placed on conditional status?

Yes

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7. Are you currently a home provider or has your home ever been certified? (*)

7. Are you currently a home provider or has your home ever been certified?

Yes

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If so what agency certified your home?

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When was it certified?

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8. Have you, or anyone in the household, been convicted of any crime?(*)

8. Have you, or anyone in the household, been convicted of any crime?

Yes

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9. Has anyone in the household ever been the subject of an investigation by a State agency involving the rights, abuse or exploitation of someone in their care/custody?(*)

9. Has anyone in the household ever been the subject of an investigation by a State agency involving the rights, abuse or exploitation of someone in their care/custody?

Yes

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10. Do you or anyone in your home smoke?(*)

10. Do you or anyone in your home smoke?

Yes

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Contractor Living Situation, Home Environment and Physical Plant

Do you

Own your home

Rent your home

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Do you have Home Owners / Renters Insurance?

Yes

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Do you see any changes in your current living situation in the next year?

Yes

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Do you understand that you may be required to update your home to meet certification standards in order to be eligible for this program?

Yes

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Experience, Educational and Training History

Do you have a High School Diploma or a GED?

Yes

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Are you certified as a (check all that apply)

CRMA

DSP

CNA

PSS

First Aid

CPR

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Please list other educational experiences, trainings and certifications

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What prompted you to pursue becoming a residential provider for a person with disabilities?

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Have you received a copy of the Shared Living Manual?

Yes

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Please describe your experience with people with disabilities or other human services below

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PLEASE NOTE! In order to be considered as an independent contractor to provide MaineCare services, it will be necessary to answer some very personal questions regarding yourself and members of your household.

The process for engaging as a Shared Living Home Provider consists of, at a minimum, the following steps:

Obtain and review the Shared Living Option Handbook issued by the
Complete the Shared Living Questionnaire.
As a Shared Living Home Provider you must meet the following basic requirements of MaineCare, the Shared Living program and the Section 21or Section 29 Waiver program:
- Background checks for you and those that live with you18 years old and
- Have a home inspection performed by Shared Living
- Training requirements must meet State requirements and be within certain time frames depending on the training, which are:
  - Shared Living Option Medication course or CRMA
  - Direct Support Professional (DSP)
  - CPR/First Aid
  - MANDT
  - Other trainings as required by the individual’s

If you become certified as a Shared Living Home Provider, additional questions will be asked of you to assist the individual, their family, their team members, case worker and the Shared Living Coordinator in making the best possible decision/match in order to provide quality supports for each individual. When a match is made, the Shared Living Provider and you will enter into a formal contract for you to provide Shared Living services as an independent contractor.

Thank you for your honest and candid responses.

Shared Living Provider Signature

Sign Above

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Date

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Please verify you are human(*)

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Our Mission:	By supporting and caring for people at all points in life, together we can make a difference.
Our Vision:	Maine ~ where individuals in need receive services that support choices for a quality life.
Our Values:	Commitment ~ Integrity ~ Compassion