Host Home Application

The Texas Home & Community - Based Service Program relies on responsible, caring, and passionate caretakers to ensure the needs of the individuals within our community is met. One form of this is through Host Home Provider. As a HOST HOME PROVIDER you are responsible for the housing, transportation, nutrition, medical, and overall necessity of an individual with IDD diagnoses within your personal home. In the application below, you will need to provide (3) references who can vouch for your ability to provide quality care for individuals in your personal home.

As a host home provider, you are an UNLICENSED caretaker and contractor within the HCS program. If contracted, you are agreeing to meet the necessity of the clients needs including securing regular transportation to & from ISS. Transportation & follow ups for medical appointments & therapies, and finally for providing hygiene, nutritional, and emotional support and care for the individuals who will live within your personal home.

Please note: Host Home Provider is a contracted title within the Ngozi Place HCS program. After background checks, an environmental check of your personal home, proper training, and availability of our clients will you be offered the ability to provide host home services within our company.

Finally, Host Home Provider is a 24/7, 365 days a year contracted position. This means if you are looking to vacation or seeking respite care for your client, YOU as a host home provider is responsible for finding the short - term relief you need. Alternatively, if you are completely unable to find quality respite care, the Ngozi Place HCS administrative team will work with you to establish a fee that is suitable and reflects the level of care of the client as payment for temporary respite. You will need to discuss this with Program Manager Ashlee McKinney.

Name

First Name

Last Name

Your Date of Birth?

You must be at least (18) years or older to be a Host Home Provider with Ngozi Place HCS.

MM

DD

YYYY

Social Security Number

Used to match name during background check(s).

Phone

(###)

###

####

Email

Your VALID Driver License Number #

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What kind of experience do you have taking care of people with Intellectual and/or Developmental Disabilites?

Host Home Providers can either transfer into an HCS program with their clients, or be assigned a client by an HCS program.

I am a CURRENT host home provider, and seeking to transfer to the Ngozi Place HCS program.

I do not have a client living with me at this time, but would like to become a Host Home Provider.

As a Host Home Provider, you will be required to provide quality living arrangements for your IDD client. This includes arrangements for, but not limited to all housing, hygiene, nutrition, medical, transportation, documentation and possibly fiscal needs of your assigned client.

I am aware of the responsibility needed to be a Host Home Provider.

I am unable to meet the needs of a IDD client in my personal home at this time.

Host Home Providers must provide their client with their own room, and unrestricted access to the other living areas of the home that are not bedrooms such as bathroom(s), living rooms or den(s), and kitchen access unless otherwise stated in a behavioral plan for safety purposes.

The client will have their own room, with no restrictions to the common areas of the home unless specified in their BSP.

I am unable to provide care for a client under these circumstances mentioned above.

The State of Texas HCS requires (3) references to vouch for your ability to provide care for individuals with IDD. Please use the line below to provide (1 of 3) references. Include their First & Last Name, and a phone number they can be reached.

The State of Texas HCS requires (3) references to vouch for your ability to provide care for individuals with IDD. Please use the line below to provide your (2nd of 3) references. Include their First & Last Name, and a phone number they can be reached

The State of Texas HCS requires (3) references to vouch for your ability to provide care for individuals with IDD. Please use the line below to provide your (3rd and final of 3) references. Include their First & Last Name, and a phone number they can be reached