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 / Province / Region ZIP / Postal Code Country
Additional info to help the matching process:
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
Additional Certifications:
- First Aid/CPR
- Certified Nursing Assistant (CNA)
- RN/LPN
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?
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Comments
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National Supports Office
4980 S. 118th St.
Omaha, NE 68137

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