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HOUSEHOLDER APPLICATION FORM (c1)

WELCOME TO SUPPORTMATCH HOMESHARE

Please use this Application Form if you are a Householder in Need of Support and Companionship in Exchange for a Spare Room to a Fully Vetted Homesharer Candidate.

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HEALTH & WELLBEING DECLARATION

IMPORTANT HEALTH CONDITIONS DISCLOSURE & DECLARATION
Supportmatch firmly believes in the importance of getting to know our Homeshare Applicants well. Therefore, we ask all our Householders to be as open and honest as possible when disclosing health conditions and personal challenges.

This helps us to sympathetically determine and match you to the right Homeshare candidate who will likely be in sync with your needs and ensures a more harmonious Homeshare match. Upholding the welfare and well-being of all parties involved is critically important to us.

We continuously manage, monitor and oversee every Homeshare arrangement, and when needed, we will step in and offer mediation to resolve any hiccups or challenges that may occur during the duration of the Homeshare arrangement.


SCOPE OF DISCLOSURE

We ask that you disclose any physical and mental health conditions, regardless of their perceived severity. This thorough disclosure is vital for evaluating the suitability of the Homeshare Arrangement.

 

CLICK TO READ HOUSEHOLDER TERMS & CONDITIONS

IMPORTANT INSTRUCTIONS

PLEASE COMPLETE *(Required) FIELDS AND CLICK SUBMIT AT THE END OF THIS FORM.

*ALTERNATIVELY, CLICK SAVE AND RESUME LATER.



HOUSEHOLDER PERSONAL INFORMATION

NOTE:

1. HOUSEHOLDER is Regular Homeshare which provides you with 10-15 hours per week of Support and Companionship
2. HOUSEHOLDER PLUS is the enhanced Homeshare arrangement which provides you with 20-25 hours per week of Support and Companionship.

HOUSEHOLDERS FULL NAME

HEALTH CONDITIONS DISCLOSURE

Please select Health Conditions relevant to you.

EMERGENCY CONTACT OR NEXT OF KIN (NOK)

We Recommend That All Our Homeshare Householder provide us with an Emergency Contact.

CONTACT & POWER OF ATTORNEY INFORMATION

Where Applicable Please Provide Information about any person who has Power of Attorney Responsibility in relation to the Homeshare Householder Applicant.

PROFESSIONAL SUPPORT INFORMATION

Professional Support would be Carer, Nurse Visits, Social Worker or any other Professional Support Services.

INITIAL HELP & SUPPORT ASSESSMENT

Please select the help and support you typically need around the house.
When are you most likely to need help around the house.
What are the days of the week that you are likely to need help.
Other help not listed above.

HOMESHARER SUPPORT DOES NOT INCLUDE OVERNIGHT ATTENDANCE SUPPORT OR PERSONAL CARE


Homesharer Support and Companionship does not include night-time Attendance Support or Personal Care. Homesharers will cover Normal Emergency Situations that may occur in the Household during the time/period they are in the property. Such Normal Emergencies would include, if required, contacting emergency services and family members. If you have any questions or concerns please call 0203 633 6066 to discuss this with a Supportmatch Homeshare Coordinator.

ABOUT YOUR ROUTINES

This section is important and will greatly help us to initially determine the Kind of Homesharer Candidate that might fit your personality and nature. We will refine the requirements and your preferences in our initial telephone assessment with a Supportmatch Homeshare Coordinator.
This section is important and will greatly help us refine the list of Homesharers that fit your requirements for Support and Companionship.

HOUSEHOLDER PROPERTY ASSESSMENT

This Assessment ensures that you are able to accommodate a Homeshare who will provide you with Support and Companionship.
If you answer NO at this time then we are sorry but the Homeshare Program requires that the Householder Offers a Spare Room in Exchange for the Companionship and Support Provided by the Homesharer.
Click or drag files to this area to upload. You can upload up to 5 files.
This is entirely optional but very much helps when we discuss and describe the options you as a Householder will offer to potential Homesharers.

DOES THE PROPERTY HAVE ANY OF THE FOLLOWING

Skip this question if you have nothing further to add.

QUALITIES IN A HOMESHARER CANDIDATE YOU ARE LOOKING FOR

HOUSEHOLDERS ACKNOWLEDGEMENT & AGREEMENT

1. To Supportmatch Homeshare Householder Terms & Conditions as Set Out in my Application.

2. To Allow Supportmatch Homeshare to Record my Personal Data and Information, for the Purposes of Facilitating and Delivering the Supportmatch Homeshare Services, which includes Matching, Monitoring and Oversight Services Provided throughout the duration of a Homeshare Arrangement following a Successful Match with a Suitable Homesharer Chosen by You the Householder.

3. I Confirm that the Information I have provided in my Application is Accurate.



INFORMATION: TO VIEW THE TERMS & CONDITIONS OF SERVICE PLEASE GO TO THE TOP OF YOUR APPLICATION AND CLICK THE LINK HOUSEHOLDER TERMS & CONDITIONS.