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Working in Partnership

Application Package

Home Share/Provider/Home Share /Home Share Application Package/June 12

Dear

Thank you for requesting information about the Tri County Home Share Program. The Tri County Home Share Program seeks to establish community living alternatives for developmentally challenged adults living in the City of Kawartha Lakes and the Counties of Haliburton and Peterborough.

Through the promotion and support of family settings, individuals will receive guidance, encouragement and opportunities for personal growth. In addition to a room rental arrangement or a room and board situation we provide financial support, information on training and assistance with the living arrangement.

Please find enclosed the following: Our brochure A brief overview of the program Community Living Kawartha Lakes Mission statement and strategic plan The Home Share Application package.

If you are interested in entering into the Home Share Program please complete the application and return to the following address:

Community Living Kawartha LakesSuite 200, 205 McLaughlin Road

Lindsay, OntarioK9V 0K7

Attention: Tri County Home Share Program

This is the first step in our extensive screening process.

If you have any further questions please feel free to call the office, Monday to Friday 8:30 a.m. until 4 p.m.

Sincerely,

Home Share Coordinator


Tri County Home Share Program

OVERVIEW

Mission

The Tri County Home Share Program will establish community living alternatives for developmentally challenged adults living in the City of Kawartha Lakes and the Counties of Haliburton and Peterborough. Through the promotion and support of family settings, individuals will receive guidance, encouragement and opportunities for growth.

Values

We believe families can have a positive impact on an individual’s growth We believe that all people should have access to safe, secure, affordable

housing within their community We believe that support should be person-centered within the context of the

family.

Goal

Our goal is to develop flexible supports recognizing the uniqueness and abilities of the individual and the family.

Services Recruitment of providers Screening of providers Orientation and skill development opportunities Intake for individual seeking family home Assessments Matching and transition Facilitating support teams Agreement negotiation Assistance arranging respite Monitoring and evaluation of placements Support for the living relationship Administration, financial and procedural

Individuals requesting a Home Share

Be developmentally challenged Be formally referred by another agency, advocate, family member or individual Provide a professional assessment if required


Participate in an individual interview, re: lifestyle, history, support needs and preferences

Wants a family home arrangement Meet the age criteria of 18 or older Sign a consent form releasing all criminal, mental or behavioural history Be on or eligible for Ontario Disability Support Provide a medical and dental reference Have access to a day program if needed Participate in yearly planning

Finding a match cannot be guaranteed. The Home Share Co-ordinator may not be able to proceed with matching when necessary financial resources, services and support are not available.

Home Share Recruitment

Potential Home Share Providers will be recruited through a variety of practices, linked closely with promotional activities. Specific advertisements, generic advertisements, flyers, word of mouth and presentations are some of the most successful avenues. Again, partnerships and linkages among similar agencies and services are useful strategies in recruiting people for the Home Share Program. Registries developed to assist with respite and contract placements are natural starting points for extending the possible contact for Home Share.

Potential Home Share Providers are asked to complete a registration package. Further screening includes all household members over 18 in the following areas:

Criminal record check Five references Family lifestyle interview Physical home study Medical Confidentiality Understanding confidentiality Proof of home and car insurance

In addition to meeting the screening requirements, the potential providers must meet the following criteria:

The home must be owned or rented independent of an agency The primary caregiver must be over the age of 18 and not immediate family of

the individual to be placed within the home.


All household members must successfully complete the orientation and screening.

There must be an understanding that the Home Share is a private not-for-profit arrangement and another source of family income is required.

Home Share Providers are in no way employees of an agency or the Home Share Program. There is a significant volunteer commitment that is required of a Home Share Provider.

The Provider must be willing to be part of the community support team around the individual.

No more than two individuals will be placed within the home, unless approved by the Ministry of Community, Family and Children’s Services.

The Tri County Home Share Program defines ‘Family’ in its most broad and indiscriminate sense. Providers may be single, married or life partners.

The provider must be mentally and physically healthy to provide support as a caregiver.

Matching and Transition

Matches cannot be guaranteed and priority will be given to homeless individuals. The Home Share Coordinator will look for:

Characteristics compatible with family life Availability of support dollars Primary support agency Day program

Transition periods are encouraged and typically look like this:

Initial meeting Dinner visit Afternoon visit Overnight visit Weekend visit

More visits may be needed and include significant others. All parties will be contacted after a visit to relate their desire for further communication and building of the relationship. The transition period is very important and should not be rushed.


Community Living Kawartha Lakes

Mission Statement

Community Living Kawartha Lakes empowers people with developmental challenges, with their families, to achieve their unique personal goals. Community Living Kawartha

Lakes leads in fostering healthy inclusive communities.

Vision Statement

People enjoy meaningful lives through connection, contribution and choice.

Values Statements

PERSON-CENTREDThe persons we serve - their goals and choices - are at the heart of all we do.

DIGNITY, RESPECT & CITIZENSHIPWe affirm the human worth, dignity and full citizenship – with all its rights and responsibilities – of every person.

CIRCLES OF SUPPORTWe commit to fostering inclusive, natural and supportive communities around those we serve.

ACCOUNTABILITYWe hold ourselves accountable to each other, to those we serve, our community, our funders and our donors in a spirit of trust and stewardship.

COLLABORATION & COMMUNITY ENGAGEMENTWe engage and collaborate with community partners in mutual efforts to create inclusive communities and meaningful choices for all we serve.

LEADERSHIP and EXCELLENCEWe value and foster leadership and excellence in all people in our organization and in our community


Community Living Kawartha Lakes

Strategic Directions 2012 to 2017

CLKL will align all programs, services, communications and governance with the organization’s Mission, Vision and Values.

CLKL will position itself to capitalize on the potential opportunities and effects of Ministry of Community and Social Service’s ‘Transformation of Services’ initiative in order to provide the most flexible and responsive services for persons with developmental disabilities.

CLKL will nurture and foster an environment that supports both Employees and Board leadership and innovation.

CLKL will build supports for inclusive neighbourhoods by engaging the community in developing natural networks and service capacity in partnership with a variety of community and area resources.

CLKL will continually seek out meaningful partnerships with and engage the advice, involvement and direction of the individuals and families it serves.

CLKL will align current funding and human resources (employees and volunteers) to serve its renewed Mission and Vision, its own deeper integration into the community of area service organizations, and will re-examine and develop policies which determine its fundraising purposes and capacity


JOIN THE TEAM!

TRI-COUNTY HOME SHARE PROGRAM

HOME SHARE APPLICATION

The Tri-County Home Share Program seeks to establish community living alternatives for developmentally handicapped adults living in the Counties of Haliburton, Peterborough and the Kawartha Lakes. Through the promotion and support of family settings, individuals will receive guidance, and encouragement and opportunities for growth.

In addition to room and board, you can receive financial support, training and assistance. You will be a very important part of a team, sharing in ensuring that we foster personal development and community support.

The application and orientation process is the first step in building lasting relationships. Your initiative and cooperation is greatly appreciated, as you will be required to complete this form and participate in a series of interviews. Asking you to clarify your abilities and expectations and strengths, ensures that everyone can make informed choices.

Applicant: (Primary Caregiver) _____________________________________________

Address: ______________________________________________________________

Home Phone:_________________ Work/Cell Phone:___________________

Other people residing at the above address?

Name M/F Age Relationship

___________________ _____ ____ ________________

___________________ _____ ____ ________________

___________________ _____ ____ ________________

Pets? _______________________ Smoking? __________________________

Do you own or rent this home? _______________ How long?______________


If rent? Landlord name/address: ____________________________________________

______________________________________________________________________

If residing here less than two years? Previous address/landlord:______________________________________________________________________

Describe your Neighborhood ______________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Transportation?___________________ Bus Route? ______________________

EMPLOYMENT:

Applicant’s Present Employer:_________________________ How Long? _____

Address: ______________________________________________________________

Applicant’s Previous Employer: ________________________ How Long? _____

Address: ______________________________________________________________

List present employment of other people in the household.

Name Employer/Address

______________________________ ______________________________________

______________________________ ______________________________________

______________________________ ______________________________________

______________________________ ______________________________________

______________________________ ______________________________________


EDUCATIONPlease list relevant education and skills ______________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

VOLUNTEER EXPERIENCEDescribe relevant experiences _____________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

MEDICALDescribe your family’s general health. (Vaccinations) ___________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

GENERALGive an overview of your family history.______________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


How did you hear about Tri-County Home Share _______________________________

______________________________________________________________________

Why do you want to be a Home Share Provider? _______________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Describe the person with whom you would share your home. _____________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

What do you need to know about the person? _________________________________

______________________________________________________________________

______________________________________________________________________

What does support mean to you? What support could you offer?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Would you participate in the following screening practices?

Criminal Record Check ____

Home Study ____

Medical ____

Proof of Insurance ____


Tri Count Home Share Program

UNDERSTANDING CONFIDENTIALITY

I have met with and received an overview and explanation of the Tri County Home Share Program.

If and when I/we are matched with a homesharer through this service, I/we undertake to be guided by the general policies and guidelines of the Tri County Home Share Program. If, by the decision of the Tri County Home Share Team, or any reason my/our application is not accepted, I/we the applicant(s) relinquish any right to question or appeal such decisions. All decisions by the Tri County Home Share Team are confidential. My/our file remains the property of Community Living Kawartha Lakes.

The undersigned acknowledges and agrees that: (1) he/she is not obligated, if called upon, to perform the services herein applied for, and (2) that the Association and the Tri County Home Share Program is not obligated to accept, match or actively seek to match him/her with a homesharer and (3) as a part of the Service’s matching process, additional personal information will be elicited from the applicant by the Tri County Home Share Program.

I CERTIFY THAT ALL THE ABOVE STATEMENTS ARE TRUE:

DATE: _____________________

APPLICANT’S SIGNATURE: ___________________________

APPLICANT’S SIGNATURE: ___________________________


REFERENCES

Please list five references that have known your family over two years. These

individuals will be contacted by mail to complete a brief questionnaire.

1. Employer ReferenceName: ___________________Address: _________________City/Town: ________________Postal Code: _______________Phone: ___________________

2. Friend’s ReferenceName: ____________________Address: __________________City/Town: _________________Postal Code: _______________Phone: ____________________

3. Family member but not spouseName: _____________________Address: ___________________City/Town: __________________Postal Code: ________________Phone: _____________________

4. Character Reference:Name: _____________________Address: ____________________City/Town: ___________________Postal Code: _________________Phone: ______________________

5. Volunteer/Past Employer/related experienceName: ______________________Address: ____________________City/Town: ___________________Postal Code: _________________Phone: ______________________

Date:____________________ Signed: ____________________________


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