R O A D T O I N D E P E N D E N C E

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    Personal Information

    Full Name*

    Date of Birth*

    Address*

    City*

    State*

    Zipcode*

    Phone*

    Email*

    How did you hear about us?*

    How many children live in your home?*


    Children Details*

    Does anyone that lives in the home smoke?*
    YesNo

    Do you have any pets?*
    YesNo

    Pet Details*

    Are the pets licensed and current on vaccinations?*
    YesNoNA
    Do the pets have a history of causing any type of injury?*
    YesNoNA

    If yes, explain*

    Support System
    Are family members supportive of your decision to become an EFH provider?*
    YesNo

    Which family members or friends can assist and support you if any? *

    Are family members or support staff willing to submit to background checks and the EFH training procedures?*
    YesNo

    Are there others in the community who can provide support to you? If so, please list their names below. *

    Religion/ Spirituality
    Would you be comfortable attending a religious ceremony outside of your religion if the client required supervision for the event?*
    YesNo

    If No, explain*

    Comfort Level

    How comfortable would you be working with an individual that has the following characteristics or behaviors on a scale of 1-5?
    1 - Very Comfortable
    2 - Somewhat Comfortable
    3 - Neutral
    4 - Uncomfortable
    5 - Very Uncomfortable

    Characterstics

    Child (Ages 0-2)*

    12345

    Adolescent (Ages 13-18)*

    12345

    Adult (Ages 19-60)*

    12345

    Male*

    12345

    Female*

    12345

    Physically handicapped*

    12345

    Poor vision*

    12345

    Special dietary needs *

    12345

    Has a diagnosis of an intellectual disability*

    12345

    Has a diagnosis of a severe and persistent mental illness?*

    12345

    Requires Physical Assistance

    Bathing*

    12345

    Toileting*

    12345

    Brushing teeth/washing face *

    12345

    Eating*

    12345

    Utilizing adaptive devices*

    12345

    Administrating medication*

    12345

    Requires Continuous Prompting

    Personal Hygiene *

    12345

    Meal Prep*

    12345

    Behaviors

    Drinks Alcoholic Beverages *

    12345

    Smokes*

    12345

    Requires 1:1 staffing *

    12345

    Requires awake hours line of sight supervision*

    12345

    Engages in verbal aggression*

    12345

    Engages in physical aggression*

    12345

    Engages in property damage *

    12345

    Engages in elopement- runs away*

    12345

    Engages in Self-Harm*

    12345

    Has attention seeking behavior*

    12345

    Has a history of sexually inappropriate behaviors*

    12345

    Registered sex offender*

    12345

    What are somethings that you cannot deal with in a person?*

    What type of client would not be appropriate for your home? *

    Relationship
    Are you currently married? *
    YesNo

    Date of Marriage*

    What are the most common conflicts in your relationship and how are they resolved?*

    Describe your partner's personality*

    What are your partner's strengths?*

    What are your partner's weaknesses?*

    What would your partner say your strengths are? *

    How do you plan to assimilate an individual into your family home?*

    Background
    Please describe your strengths, and qualities that help you succeed and get along with others*

    Describe your weakness*

    Describe your personality*

    Describe your current state of health *

    What was the date of your last physical examination? *

    What was the outcome of the physical? *

    Do you have any medical/mental/physical issue which would limit your ability to provide care for a client?*

    Have you received mental health care in the past (including but not limited to individual or family therapy, psychiatric or psychological evaluations or appointments, inpatient hospitalizations, etc.)? *
    YesNo


    if yes, please explain*

    How often do you drink alcohol? *
    DailyWeeklyMonthlyI Don't Drink

    How much do you drink? *

    Have you ever used illegal drugs? *
    YesNo

    Have you ever had problems as a result of your drug/alcohol use? *
    YesNo

    Have you ever received treatment for the use of drugs or alcohol? *
    YesNo

    Are you currently or in the past been arrested, charged, or convicted of a criminal offence; been placed on probation or parole or in any way been subject to the criminal justice system? Please Note that this includes instances where you were ticketed but Not charged, were fingerprinted for any reason and instances that the crime was expunged from your record. *
    YesNo

    Please detail any tickets, arrests, convictions, etc. Please include the date and circumstances of the event. *

    Have you lived outside of the state of Nebraska within the last 5 years? If so, list where and dates*

    Vehicle
    Do you have a working, licensed, and insured vehicle?*
    YesNo

    Do you have a Nebraska driver's license? *
    YesNo

    Are you willing to provide transportation for outings, doctor appointments, meetings, etc.? *
    YesNo

    Do you have any infractions against your driver’s license within the last 5 years? *
    YesNo

    If yes, please explain *

    Refrences
    List at least 3 personal references (name, address, phone,): *

    Address:

    1905 Harney St #150
    Omaha, NE 68102

    Phone:

    +1 402 598 0517
    +1 402 320 1889

    Email:

    sheena@remedyroadllc.com
    anton@remedyroadllc.com

    Remedy Road LLC
    We value each client and their families and will show respect and dignity to everyone.

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