Questions? Call us. (531) 500-4729

Questions? Call us. (531) 500-4729

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Shared Living Provider Application

SHARED LIVING PROVIDER APPLICATION

Developmental Educational and Behavioral Outcomes is an equal opportunity provider and encourages diversity in our associations. Shared Living Providers are independent contractors and not employees of the agency. Developmental Educational and Behavioral Outcomes makes all placement decisions without regard to an applicant’s race, religion, sex, age, national origin, sexual orientation, disability, or other protected classifications under federal, state, or local equal opportunity laws.

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Referred By:
Are you at least 18 years of age?
Are you authorized to work in the United States on an unrestricted basis?
Have you ever worked for Developmental Educational and Behavioral Outcomes?
PLACEMENT DESIRED
Date available
Do you have an individual identified you would serve:
Are you currently a Shared Living home provider?
Do you own your home or rent/lease and are currently listed as a tenant on the leasing agreement?
Placement Preferences:
Are pets present in the home?
Do residents of the home need to use stairs?
First Name, Age, Relationship to Sub-contractor
QUALIFICATIONS
Do you have automobile insurance coverage?
Have you received three or more traffic violations in the last 3 years?
Has your driver’s license been suspended or revoked in the last 3 years?
Have you ever been convicted of a crime or are you subject to a pending criminal charge?
(No applicant will be denied solely on the grounds of a conviction or pending criminal charge. The nature of the offense, the date, the surrounding circumstances, and the relevance to placement will be considered.)
EDUCATION
High School/GED:
Technical/Vocational:
College/University:
Other
SPECIALIZED TRAINING, CERTIFICATION, OR EXPERIENCE
Training/Certification
Do you have experience in providing care or treatment for persons with any of the following:
Are you able to speak a language other than English?
WORK HISTORY
If you are currently employed, may we contact your employer?

Begin with current or most recent employer or position with employer:

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REFERENCES

Developmental Educational and Behavioral Outcomes requests that all applicants submit six (6) references, which may include: current or former contracting providers, employers, supervisors, teachers or others qualified to objectively evaluate your ability to provide the services for which you have applied.  Please list the reference information identified below.  Developmental Educational and Behavioral Outcomes reserves the right to contact some or all of your references. 

Three Provider/Work References
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Three Personal References

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THANK YOU FOR YOUR INTEREST IN DEVELOPMENTAL EDUCATIONAL AND BEHAVIORAL OUTCOMES

We at Developmental Educational and Behavioral Outcomes are pleased you are interested in becoming a member of our Company. We are proud of our excellent reputation and the services we provide. We value diversity and want your experience with us to be enjoyable. Therefore, to help ensure a safe home environment and excellent services, we carefully screen the background of all applicants. This screening may include an oral interview, as well as an investigation of your work history, driving record, application information, and reference checks. 

Developmental Educational and Behavioral Outcomes requires that an investigation of your background for any criminal conduct be completed upon prior to contracting and may be repeated randomly or as required by law thereafter.  Some service areas may also require a screening for the use of illegal drugs.

APPLICANT DECLARATION OF UNDERSTANDING

  • I understand that Developmental Educational and Behavioral Outcomes may conduct an investigation of the information I have noted on this application and, as part of that investigation, may contact prior employers and references, among others. I authorize Developmental Educational and Behavioral Outcomes to conduct this investigation and I release from all liability and hold harmless any person giving or receiving information about me relative to this investigation.
  • I understand that any falsification, misrepresentation, or omission of information discovered as a result of this investigation may prevent my eligibility to contract or may subject me to the immediate termination of my contract with Developmental Educational and Behavioral Outcomes.
  • I understand that this application process does not create a contract.
  • I declare that I have never committed nor been charged or convicted of any act of abuse, neglect, exploitation, or fraud in relationship to a dependent/vulnerable child or adult within the past 10 years.
  • I declare that I have never knowingly violated any applicable rules or laws in any previous employment in a residential, healthcare, or similarly related employment.
  • I declare that the Office of Inspector General has never excluded me from participating in the Medicaid or Medicare programs.

By signing this application, I agree that I have read and understand the declarations listed above and I assert that all information given in this application is true.

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