Become a Mosaic at Home Provider

Make a meaningful, life-long friendship while sharing your home with someone with an intellectual or developmental disability.

LEARN MORE

Thank you for your interest in being a Mosaic at Home provider! Please fill out the full questionnaire below.

Step 1 of 9

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GENERAL

First Name(Required)

Middle Initial

Last Name(Required)

Street Address(Required)

City(Required)

State(Required)

ZIP Code(Required)

Address of the Home You Will Provide Services In (if different)

City

State

ZIP Code

Home Phone

Cell Phone(Required)

Email Address(Required)

Do you have a valid driver's license?(Required)

Yes

Are you eligible to work in the human services field according to your state’s requirements?

Yes

Are you willing to relocate to provide services?

Yes

Other

Have you previously worked for Mosaic?(Required)

Yes

If yes, indicate where, when and reason for leaving:

GENERAL (Continued)

How many individuals are under 18?

How many people would be living in the home?

Check all areas you have familiarity with:

Mental/Behavioral Health

Physical/Personal Care-Taking

Adaptive Mobility

Medication Administration

Community Integration

Habilitation

Feeding Tubes and Dietary Specialties

None of the Above

Additional Certifications:

First Aid/CPR

Certified Nursing Assistant (CNA)

RN/LPN

None of the Above

Please check all features that apply to your home:

ADA accessible

Ranch Style

Split-Level

Swimming Pool

Apartment/Condo

Neighborhood Features:

Rural

Urban

Suburban

Parks/Libraries/Other Recreational Activites

Easy Access to Public Transportation

How did you hear about Mosaic?

EDUCATION

High School Name, Location (City/State), Start Date and End Date

(Ex: Central High School, Omaha, NE, August 2007 - May 2011)

Did you graduate from this school?

Yes

College/University Name, Location (City/State), Start Date and End Date

(Ex: University of Nebraska-Lincoln, Lincoln, NE, August 2011 - May 2015)

Major

Did you graduate from this school?

Yes

Other School Name, Location (City/State), Start Date and End Date

(Ex: University of Nebraska-Lincoln, Lincoln, NE, August 2011 - May 2015)

Major

Did you graduate from this school?

Yes

Scholastic Honors/College or High School Activities:

Certifications (specify states of registration and license number):

Please include copies of each certification as applicable (CPR, First Aid, Medical Certification, Crisis Intervention, CNA, etc.).

Drop files here or

Max. file size: 300 MB.

Please list any skills/hobbies of interest:

EMPLOYMENT HISTORY - EMPLOYER 1

Employment Start Date

Employment End Date

Company Name

Company Phone Number

Starting Salary

Ending Salary

Supervisor's Name

Type of Business

May we contact this employer?

Yes

Reason for Leaving

EMPLOYMENT HISTORY - EMPLOYER 2

Employment End Date

Employment Start Date

Company Name

Company Phone Number

Starting Salary

Ending Salary

Supervisor's Name

Type of Business

May we contact this employer?

Yes

Reason for Leaving

ENVIRONMENTAL INFORMATION ABOUT THE HOST HOME/INDEPENDENT CONTRACT SETTING

Please list all members of your household:

Name, age, relationship

(Ex: John Doe, 45, Husband)

Name, age, relationship

(Ex: John Doe, 45, Husband)

Name, age, relationship

(Ex: John Doe, 45, Husband)

Name, age, relationship

(Ex: John Doe, 45, Husband)

Name, age, relationship

(Ex: John Doe, 45, Husband)

Name, age, relationship

(Ex: John Doe, 45, Husband)

Please submit a minimum of two high resolution* photos (at least 500K in file size) of the Host Home Provider and/or family.

Drop files here or

Max. file size: 300 MB.

These photos should include the person providing services, as well as any additional family members or pets that reside in the home.

Photo Descriptions

Please include photo captions to help us identify who's featured in the photos.

Briefly describe your home. Make note of special features that would be of assistance to you in providing services in the Host Home Program. (List special features such as wheelchair accessibility, special amenities such as spare rooms, fenced yard, recreational areas, etc.)

Photos of the Home

Drop files here or

Max. file size: 300 MB.

Recommended photos: The outside of the home; the living area, family room or any shared space in the home; the bedroom that the person would have; and the backyard of the home

Please list a total number of rooms. Include types of rooms (bedrooms, bathrooms) and number of staircases.

Please indicate the number and location of any fire extinguishers, smoke and carbon monoxide detectors in your home.

Do you have a landline phone? Cell? Internet?

Do you own pets or livestock? If yes, please provide information.

Briefly describe your neighborhood. Include distance to neighbors, stores, recreational areas, medical and emergency support services. (List anything that would be of assistance to you in providing Host Home supports)

TRANSPORTATION

Can you provide reliable transportation to meet the needs of the people in your home on a daily basis?(Required)

Yes

If no, please provide details:

Please list names of all persons who will be transporting the people you serve:

Please attach copies of the driver’s license(s) and proof of insurance to be used for transportation for all persons who will be transporting the people you serve.

Drop files here or

Max. file size: 300 MB.

NOTE: Prior to providing transportation, a motor vehicle record check (MVR) must be completed by Mosaic prior to transporting the people you serve.

HOMEOWNERS/RENTERS/AUTO INSURANCE

Please attach copies of your homeowners/renters insurance coverage.

Drop files here or

Max. file size: 300 MB.

Company Name, Policy Number

(Ex: State Farm, 123456)

Company Name, Policy Number

(Ex: State Farm, 123456)

REFERENCE 1

Name(Required)

Address(Required)

Company

Phone Number(Required)

Reference Type

Personal

Professional

REFERENCE 2

Name(Required)

Address(Required)

Company

Phone Number(Required)

Reference Type

Personal

Professional

REFERENCE 3

Name(Required)

Address(Required)

Company

Phone Number(Required)

Reference Type

Personal

Professional

INTERESTS

Hobbies:

Special Interests:

Testimony about why the provider has an interest in opening their home to someone with an intellectual or developmental disability, what they are looking forward to, their connection with Mosaic, etc.:

Additional Info to Help the Matching Process:

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