3231 Kingsway - Vancouver, B.C. V5R 5K3

Phone (604) 323-1433 Fax (604) 321-4144

SHARED LIVING – DETAILED CAREGIVER APPLICATION FORM

PLEASE NOTE: If you are a new applicant, please complete the “Caregiver Application – Basic.” The basic application is available online under the “Links” section of the Spectrum Shared Living website. The detailed form may be downloaded to your computer and completed as a Word document, or printed out and completed manually.

The following detailed application is for applicants who have already submitted a basic form and have been asked to provide us with more information. Please read through the questions before you start answering them, and take some time to discuss with your partner and/or family. Consider your own personal values as you complete this application, and provide as much detail as possible to help us get to know you better. When you are finished, please mail or drop off the printed application to the address above, or send the completed Word document as an email attachment to our Shared Living coordinator: .

Caregivers undergo an extensive screening process that includes a criminal records search and detailed home study. We will provide you with more information on these requirements when we meet you.

Your name / Date

(Check one)

I will be the primary support provider

I will be the secondary support provider

(Check one)

I am willing to move in order to offer support to an individual

I am not willing/able to move

Please describe your house and space available:
Address (including postal code):
Phone: / Secondary phone:
Email: / Fax number:

OTHERS LIVING IN YOUR HOME:

Name / Relationship / Age
1. Do you work outside the home or attend school? Please describe:
2. Do you currently provide care to someone in your home, on a full-time or respite basis?
3. What other commitments do you have, ie. groups you belong to, clubs, sports teams, faith community?
4. Do you plan to make any significant changes to your lifestyle in the foreseeable future? Eg. getting married, going back to school, starting a new job, travelling?
5. How do you like to spend your spare time? Describe any hobbies or special interests you have. Do you prefer being indoors or outdoors / being physically active or not so much?
6. Describe your personal support network (family, friends, co-workers, professional supports):
7. Would you say that you and your family / partner have a strong network of support? What steps do you take to strengthen and maintain your personal support network?
8. (Couples) How long have you been together as a couple? Describe some of the adjustments you’ve made in order to make your relationship successful.
9. How do you and your partner / family communicate with each other, and how do you deal with disagreements?
10. What kinds of things cause stress in your life? How do you deal with stress?
11. How do you make decisions as a couple / as a family?
12. If there are children in the home, describe their interests, hobbies, typical routines:
13. What activities do you do together as a family or as a couple, and how often?
14. What impact might the addition of a person with special needs into your home have on your family and on your relationship with your partner?
15. What are your expectations regarding the involvement of a person with special needs in your family activities and day-to-day routines?
16. What arrangements would be made if the person with special needschose not to participate in your family activities or outings?
17. How might you support the person with special needs to develop friendships, and to maintain the friendships that they already have?
18. How might you support the person with special needs to maintain and strengthen the relationships they have with their family members?
19. Caregivers are expected to arrange their own respite as required, for example if they are ill, going on vacation, or just need a break. Please describe your plan for providing appropriately trained respite care for the person:
20. What languages do you speak?
21. Have you applied to other agencies to provide shared living or home sharing services?
22. Why do you want to be a Shared Living provider?
23. Any other information you’d like to share?

24. Please indicate your level of experience with the following:

Yes, a lot / Yes, a little / No, but willing to learn / No
I have experience providing support to people with special needs (work experience, peer tutoring at school, related education or training)
I have life experience with people with special needs (family member, friend, co-worker, etc)
I have experience assisting people with personal care (bathing, grooming, using the toilet, etc)
I have experience with augmentative / alternative communication (ie. communicating with someone who doesn’t speak or has limited speech)
I have experience with people who use assistive devices or equipment (walker, crutches, technological devices)
I have experience with people who are deaf or hard of hearing
I have experience with people who are blind or have low vision
I have assisted someone who has physical support needs (lifts, transfers, pushing a wheelchair)
I have experience with people with autism
I have experience with people who have an acquired brain injury (ABI)
I have experience with people who have epilepsy / seizure disorders
I have experience with people who have mental health issues (bipolar disorder, schizophrenia, eating disorders, depression)
I have experience with people who have addiction issues (drugs, alcohol, sex, gambling)
I have experience with people who have challenging behavior (aggression, self-injurious or impulsive behavior)
I have experience with people who have high health care needs (chronic illness, dementia, complex personal care)
I have experience supporting someone with high energy / someone who enjoys a high level of activity
I have experience with teaching / coaching / supporting the learning of someone with special needs
I know how to prepare healthy meals that satisfy the nutritional needs of others, including special dietary requirements (eg. vegetarian, diabetic diet)
I know about and use local resources in my community (eg. recreation centres, parks, public transportation)
25. Other related experience or skills:
26. Would you be comfortable supporting an individual who has some of the special needs described above? Please note any concerns or exceptions:
27. Based on all of the above information, would you be comfortable supporting someone who needs a high level of support, a moderate level of support, or minimal support? Please be as specific as possible:

Employment history

Please provide information on your employment history, starting with your most recent (or current) employment.

Employer:
Start date: / End date:
Position:
Describe duties and responsibilities:
Why did you leave this position?
Supervisor’s name and contact information (for reference / verification of employment):
Employer:
Start date: / End date:
Position:
Describe duties and responsibilities:
Why did you leave this position?
Supervisor’s name and contact information (for reference / verification of employment):
Employer:
Start date: / End date:
Position:
Describe duties and responsibilities:
Why did you leave this position?
Supervisor’s name and contact information (for reference / verification of employment):

Education

Please list any degrees, diplomas, or certificates you have completed or are in the process of completing:

Degree, diploma or certificate / Educational institution / Year completed

Do you have a personal relationship with anyone at Spectrum (employee, caregiver, family or person served)? Answering “yes” will NOT disqualify you from becoming a caregiver.

Yes

No

Thank you for completing the detailed Shared Living application.

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Current:November 2011