Become a Mosaic at Home Provider

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

Name*
First Last
Email Address*
Phone Number
Address of home you will provide services in:*
Street Address Address Line 2 City State ZIP Code
Additional info to help the matching process:
Do you have a valid driver’s license?*
- Yes
- No
Are you eligible to work in the human services field according to your state’s requirements?*
- Yes
- No
Are you willing to relocate to provide services?*
- Yes
- No
How many people would be living in the home?
How many are individuals under 18?
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 Activities
- Activities Easy Access to Public Transportation
How did you hear about Mosaic?
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

National Supports Office
4980 S. 118th St.
Omaha, NE 68137

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