COMMUNITY CARE CONNECTIONS OF WISCONSIN

ADULT FAMILY HOME PROVIDER APPLICANT QUESTIONNAIRE

APPLICANT 1

Last NameFirst NameFull Middle Name

Social Security NumberBirth DateBirth Place

APPLICANT 2

Last NameFirst NameFull Middle Name

Social Security NumberBirth DateBirth Place

RESIDENCE

AddressCity StateZip

CountyTownship or Village

Home PhoneBusiness PhoneCell Phone

Directions to your home: ______

______

How long have you lived at this address? ______

How long have you lived in Wisconsin? ______

EDUCATION

Please provide school name, years attended, graduation dates, degree earned.

APPLICANT 1 / APPLICANT 2
High School
PostHigh School
Are you currently enrolled in school?
Name of course study.
Have you served in the Military? What branch, dates, where, exit rank, reason for discharge?

EMPLOYMENT HISTORY

Applicant 1

EMPLOYER / POSITION / HOURS / DATES OF EMPLOYMENT / REASON FOR LEAVING

Applicant 2

EMPLOYER / POSITION / HOURS / DATES OF EMPLOYMENT / REASON FOR LEAVING

YOUR FAMILY

CHILDREN

Please include all children, even if they are not a resident in the home, including adult children.

Name / Sex / Birth Date / Address if Different / Grade / School/
Employment

OTHER HOUSEHOLD MEMBERS

Name / Sex / Birth Date / Address if Different / Grade / School/
Employment

EACH APPLICANT SHOULD ANSWER THE FOLLOWING QUESTIONS

Describe your own children’s personalities.

How do they feel about sharing their home and your time with an adult placed in your home?

Describe any special needs of your child(ren) or other family members.

Please list hobbies, interests, clubs, organizations, and activities your household regularly participates in.

PETS

Describe any pets in the home. ______

______

Are their vaccinations up to date:Yes No * Please provide documentation of rabies vaccine.

GENERAL HEALTH STATUS

Applicant 1 Excellent Good Fair Poor

Applicant 2 Excellent Good Fair Poor

Children or Other Household Members:

______ Excellent Good Fair Poor

______ Excellent Good Fair Poor

______ Excellent Good Fair Poor

______ Excellent Good Fair Poor

______ Excellent Good Fair Poor

______ Excellent Good Fair Poor

Describe any health problems in the household:

DESCRIPTION OF YOUR HOME

Number of people you would like to be certified for. 1 2Respite Only

Type of Residence: House Duplex Apartment Mobile Home Other ______

 Own Rent

Describe the location (floors, up or down, basement) of your rooms:

Describe sleeping accommodations available for those you would be caring for (closet, windows, etc). Please include accurate room dimensions.

Describe your neighborhood.

Is your home wheelchair accessible? Would you consider adaptations to your home?

Do you have any restrictions on the use of your home or furniture by members you would be caring for? Explain.

Do you have household items which would be considered dangerous? (Example: firearms, medications, toxic chemicals, etc.) What precautions will you take?

Do you have an emergency evacuation plan for a...

  1. Fire? Describe.
  1. Severe weather? Describe.

How do you resolve disagreements?

Why do you want to become an adult family home provider?

Describe the type of person(s) you wish to care for. (Elderly, physically, disabled developmentally disabled). If you only specified one demographic, would you be interested in considering others? How would you feel about someone recovering from drug or alcohol abuse?

If you would consider caring for a physically or mentally disabled adult, describe you experiences or abilities to do so.

Would you accept adults of different ethnic and religious backgrounds? Explain.

What type of adult would you NOT accept for placement?

Describe any other helpful experiences that would relate to caring for others in your home.

How did you learn about becoming an Adult Family Home provider?

Why did you decide to apply at this time?

What do you think will be difficult about caring for someone in you home?

Have you applied for an Adult Family Home certificate before? Yes No 

Were you certified? ______

Where?______

Is your certification still current?______

TRANSPORTATION

Do you have a valid driver’slicense? Applicant 1 Yes No Applicant 2Yes No 

If no, please explain. ______

Any there any restrictions on your license? Applicant 1 Yes No  Applicant 2Yes No 

If yes, please explain. ______

Do you have a car available? Yes No 

Are you able to providetransportation to those residing in your home? Yes No 

Are you willing to attend staffings, workshops, conferences, medical appointments, counseling sessions, etc. with or regarding placements in your home? Yes  No  If no, explain ______

______

FAMILY FINANCIAL INFORMATION

ANNUAL GROSS INCOME / Applicant 1 / $
Applicant 2 / $
Other Income (Specify) / $
Other Income (Specify) / $
TOTAL / $
MONTHLY EXPENSES / Mortgage or Rent / $
Auto / $
Utilities / $
Bank Loans / $
Groceries / $
Credit Cards / $
Student Loans / $
Miscellaneous / $
TOTAL / $
ASSETS / Current Home Value / $
Savings Account(s) / $
Stocks and Bonds / $
Retirement Plans / $
Other assets (specify) / $
TOTAL / $

Do you have medical insurance?Yes No  With whom ______

Do you have homeowner’s insurance?Yes No  With whom______

Do you have auto insurance?Yes No  With whom______

* Please note - you will need to provide a copy of your homeowner’s and auto insurance paperwork for review. You must have a minimum of $300,000 in homeowner’s liability coverage to be eligible. You must also notify your carrier that you are considering becoming an Adult Family Home to ensure your coverage will not be dropped.

Do you have life insurance?Yes No 

Are you under a retirement plan?Yes No  Explain. ______

Are your taxes up to date?Yes No 

Have you ever declared bankruptcy?Yes No 

If yes, when? ______Where? ______

Name of your bank(s). ______

REFERENCES

List five people who you know well who may be contacted to provide a personal reference. Only one may be a relative. Please provide their COMPLETE mailing address, including zip code.

NAME / COMPLETE ADDRESS / TELEPHONE

In completing this questionnaire, I (we) understand there is no guarantee by Community Care of Central Wisconsin (CCCW) that an adult will be placed in my (our) home. I (we) also understand that CCCW is free to consult persons or agencies named herein. The information contained in the questionnaire is true and correct to the best of my (our) knowledge.

Signature Applicant 1Date

Signature Applicant 2Date

Upon completion, please return form to:

Provider Relations Coordinator-AFH Certifier

Tina Plachetka

1200 Lakeview Drive, Ste 100

Wausau, WI 54403

(715) 301-1702