Shared Living Provider Information Form
To start the process of becoming a Shared Living provider, please complete this short, online questionnaire. It will help us gather a little more information about you and your home, understand what kind of placement would be appropriate and determine if Shared Living is right for you.
 
1.
Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.

Do you have experience working with people with disabilities? (not required)

 

350 characters left.
3.

Do you have experience with Shared Living?

 

350 characters left.
4.
Do you have an extra bedroom? (required)
 

50 characters left.
5.
How many people live in your home? Ages?
 

50 characters left.
6.
Do you have a Massachusetts driver's license and car? (required)
 

50 characters left.
7.
Is your home wheelchair accessible? (not required)
 

50 characters left.