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Family Study


Current RVS Employee?

May we contact your current employer?

Have you been a care provider before?

Do you have a valid Drivers License?
Would you be willing to provide local transportation for outings, Dr. appointments, ETC?

Household Members:


Employment History

Have you ever been arrested for anything?

Living Arrangments
Would you accept an individual who: (Please check all that apply)

List 3 personal references (non-relatives):

Person 1
Person 2
Person 3

We at Region V Services have an expectation of values. We also expect all members of our team to share the same values.  Please tell us how you would express each value. 

H.O.M.E.S. stands for:  Heart, Opportunity, Morals, Education, and Support.

Heart; Family isn’t always blood. It’s the people in your life who want you in theirs; the ones who accept you for who you are. Write about what Heart means to you and how you would provide heart within Region V Services and as a subcontractor for a person living with you.
Opportunity; Extended Family Homes provide choices: where to live, who to live with, and outcomes people desire to achieve. Write about what kind of Opportunities you would provide for an individual we support.
Morals; At Region V Services we strive to ensure an environment of trust. Please describe what Morals you value and how they can help to build trust within the team.
Education; Tell me and I forget. Teach me and I remember. Involve me and I learn! Education is a key part of what we do here at Region V Services. Please describe a program that you would implement for someone who has behaviors of verbal aggression. What would the program recommend to do to cope with feelings, recommend alternative behaviors/actions, and how you should react when behaviors are present?