Access Services - Creating Better Ways To Serve People With Special Needs

Initial Contact Form for Provider Applicants
  1. (*) = required field
  2. Name(*)
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  3. Street Address(*)
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  4. City(*)
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  5. State(*)
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  6. Zip(*)
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  7. Phone(*)
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  8. Area of Interest(*)
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  9. Answering the following questions would be helpful but are not required.
  10. Email
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  11. How many people are living in your household?
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  12. Ages and relationships
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  13. Do you have sufficient room to add a person to your family?
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  14. Do you have reliable transportation?
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  15. Do you have a valid driver’s license?
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  16. Do you have a source of income to meet your family’s needs?
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  17. Are you willing to attend in-service training prior to approval?
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  18. Have you ever worked with another agency?
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  19. If yes, what is the name of the agency and in what capacity?
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  20. Are you currently providing day, foster or elderly care in your home?
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  21. Are all members of your household free from communicable diseases to include, but not limited to, Hepatitis A, B, or C, Aids, and Tuberculosis?
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  22. Do you have experience working with people who either have a developmental disability, mental health concern, or learning disability?
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  23. Do you have a family member with a disability?
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  24. Where did you hear about our program? Where did you see an ad?
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  26. Thank you very much for completing this form and for your interest in becoming a host family for Access Services.

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