Application type* must provide value
Full Time
Respite/Part time/ Occasional
Applicant's Name* must provide value
City* must provide value
WV County* must provide value
Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan McDowell Marion Marshall Mason Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming
Email* must provide value
Home Phone Number
Cell Phone Number
Business Phone
Directions to home (Please include a clear description of the outside home):
Road condition (i.e. grave, paved, dirt)
Please provide any additional information concerning the home/neighborhood (I.e. large dog in yard, especially steep driveway, etc.)
Do you own or rent your home?* must provide value
Own
Rent
Length at Address
Number of Rooms
Would a person placed in your home have his/her own bedroom?* must provide value
Yes
No
Source of Heat
Electric
Natural Gas
Propane Gas
Wood/Coal
Source of water
Community Water
Well Water
Name of Applicant* must provide value
Name of Applicant's Spouse
Race/Ethnicity
Spouse Race/Ethnicity
Religious Preference
Age
Spouse Age
Highest Grade Completed
Spouse Highest Grade Completed
Degree/Certification Received
Spouse Degree/Certification Received
Additional Training
Spouse Additional Training
Occupation/Job Title
Spouse Occupation/Job Title
Employer
Spouse Employer
Years of Service
Spouse Years of Service
Hours worked per week
Spouse hours worked per week
Shift worked
Spouse shift worked
Income Range
$10,000 - $30,000 $30,000 - $50,000 $50,000 - $80,000 $80,000 - $100,000 $100,000+
Spouse Income Range
$10,000 - $30,000 $30,000 - $50,000 $50,000 - $80,000 $80,000 - $100,000 $100,000+
Source of income other than employment
Spouse source of income other than employment
Relationship (married, cohabitating, other)
Date of marriage
Today M-D-Y
List any serious illnesses, operations, chronic conditions, or physical, disabilities of household members, including the name of the member.
List any emotional or psychiatric illnesses of any household member, including the name of the member.
List any significant substance use (past or present of alcohol, drugs or tobacco) of any household member, including the name of the member.
Do you have reliable transportation?* must provide value
Yes
No
Are all vehicles properly licensed and insured?* must provide value
Yes
No
List names of household members who are licensed drivers
Distance to nearest hospital
Distance to nearest pharmacy
Distance to the nearest doctor's office
Distance to the nearest grocery store
Distance to the nearest park/recreation area
What is the name of your area elementary or primary school?
What is the name of your area middle or junior high school?
What is the name of your area high school?
List any convictions or civil suits (except for minor traffic violations) and the name(s) of the household member(s) involved.
Has any household member provided services through the WVDHHR previously? If so, please list service(s) provided, dates of services, and by whom.* must provide value
Has any household member received services from the WVDHHR? If so, please list service(s) received, dates of services, and to whom.
Describe any experiences you have had with individuals with physical, intellectual and/or developmental disabilities.
What motivated you to apply to provide Specialized Family Care?
Preferred age for an individual that may be placed in your home.
Birth to 5
6-11
12-17
Adult
Any Age
Gender
Male
Female
Either
Race/Ethnicity
Caucasion
African American
Asian American
Native American
Latin American
Pacific Islander
Multi-racial
Any Race
How did you hear about the Specialized Family Care Program?* must provide value