Home Sharing Application - Detailed - Spectrum Society for Community Living

Thank you for your interest in Spectrum’s Home Sharing program. Please complete the following detailed application form.

Step 1 of 6

16%

Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Support provider - check one(Required)

I will be the primary support provider

I will be the secondary support provider

Able to move - check one(Required)

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(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Phone(Required)

Secondary Phone

Email(Required)

Fax number

Others living in your home

Name, relationship and age

I am able to offer support to an adult / youth who needs(Required)

Check all that apply and outline the supports you can offer in the areas that you ticked in the section below.

A high level of support

A moderate level of support

A minimum level of support

No support. I will rent out a suite or space in my home

High level of support information

Moderate level of support information

Minimum level of support information

No support information

Do you have a preference for a male or female, youth or adult, specific age group? Please describe(Required)

What commitments do you have in your life at present or in the foreseeable future?(Required)

Eg. do you attend school or work outside the home? Do you plan to make any significant changes to your lifestyle in the near future?

Describe your personal support network(Required)

(family, friends, co-workers, professional supports):

Do you feel that you and your family / partner have a sufficient network of support? If not, what steps might you take to strengthen your support network?(Required)

(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.

How do you and your partner / family communicate with each other, and how do you deal with disagreements?(Required)

What kinds of things cause stress in your life? How do you deal with stress?(Required)

How do you make decisions as a couple / as a family?(Required)

If there are children in the home, describe their interests, hobbies, typical routines:

What activities do you do together as a family or as a couple, and how often?(Required)

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?(Required)

What are your expectations regarding the involvement of the person with a disability in your family activities and day-to-day routines?(Required)

What arrangements would be made if the person with a disability chose not to participate in your family activities or outings?(Required)

How might you support the person with a disability to develop friendships, and to maintain the friendships that they already have?(Required)

How might you support the person with a disability to maintain and strengthen the relationships they have with their family members?(Required)

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 with a disability when required.(Required)

What languages do you speak?(Required)

Have you applied to other agencies to provide shared living or home sharing services?(Required)

Why do you want to be a Shared Living Caregiver?(Required)

Please attach your resume that includes any related experience and education.

Accepted file types: pdf, doc, docx, ppt, pptx, Max. file size: 32 MB.

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Home Sharing Application – Detailed

Thank you for your interest in Spectrum’s Home Sharing program. Please complete the following detailed application form.

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